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SERVICE REQUEST <br />Type of Business or Property <br />I: <br />El <br />Veronica Freitas <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE # Exr. <br />Walton Engineering, Inc. <br />916 373-1167 <br />gas station <br />FAX # <br />P.O. Box 1025 <br />OWNER /OPERATOR <br />CITY West Sacramento <br />STATE CA Zip 95691 <br />Quik <br />Stop Markets, Inc. <br />CHECKif BILLING ADDRESS <br />FACILITY NAME <br />Quik <br />Stop # 124 <br />SITE ADDRESS 505 <br />N <br />Main Street <br />Manteca <br />T�5336 <br />Street Number <br />Direction <br />Street Name <br />Cit <br />i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4567 <br />Enterprise Street <br />Street NumberF <br />Street Name <br />CITY Fremont <br />STATE CA ZIP <br />94538 <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTORSERVICE <br />REQUESTOR <br />I: <br />El <br />Veronica Freitas <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Exr. <br />Walton Engineering, Inc. <br />916 373-1167 <br />HOME or MAILING ADDRESS <br />FAX # <br />P.O. Box 1025 <br />(916 ) 373-1173 <br />CITY West Sacramento <br />STATE CA Zip 95691 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 4/12/14 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Ispp ded t0 me Or <br />my representative. - :n_ FAr4. <br />TYPE OF SERVICE REQUESTED: ZI 5 1— � 7 C®j IAQ. <br />COMMENTS: 'o <br />�dT <br />ACCEPTED BY: EMPLOYEE#: 967 DATE: ' <br />ASSIGNED TO:EMPLOYEE #:®U` DATE: 7!'/ <br />Date Service Completed (if already completed): SERVICE CODE: � < e P I E: 11—:30Fee Amount: 1d' Amount Pai 375 ® (7 PaymenteDate 4-1G <br />Payment Type Invoice # Check # [� 7 y� Rec ved B <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />