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SAN JOAQ16 COUNTY ENVIRONMENTAL HEALTilaPARTMENT Type of Business or Property - -- - -- __ CHECK if BILLING ADDRESS® FACILITY ID # SERVICE REQUEST # gas station ROME or MAILING ADDRESS P.O. Box 1025 EMPLOYEE #: FAX# (916 ) 373-1173 OWNER / OPERATOR STATE CA Zip 95691 Quik Stop Markets, Inc. CHECK if BILLING ADDRESS❑ FACILITY NAME Payment Date Quik Stop #124 Invoice # SITE ADDRESS 505 N Main Street Manteca 95336 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street Street Number Street Name CITY Fremont STATE CA Zip 94538 PHONE #1 EXT ( ) APN # LANDUSE APPLICATION # PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICEW0111 REQUESTOR Veronica Freitas - -- - -- __ CHECK if BILLING ADDRESS® BUSINESS NAME Walton Engineering, Inc. EMPLOYEE #: PHONE # EXT• 916 373-1167 ROME or MAILING ADDRESS P.O. Box 1025 EMPLOYEE #: FAX# (916 ) 373-1173 CITY West Sacramento STATE CA Zip 95691 t2ILLir-Au A(:KN0WLE0GEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 4/12/14 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Contractor If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 07/17/08 SR FORM (Golden Rod)