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SAN JOAQUTAOUNTY ENVIRONMENTAL HEALTHIPPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #++ SERVICE REQUEST # Gas Station ol to fl o'� OWNER / OPERATOR CHECK If BILLING ADDRESS Quik Stop Markets, Inc. ExT. Walton Engineering, Inc. DATE: FACILITY NAME SERVICE CODE: t 8 Quik Stop #124 Fee Amount: S SITE ADDRESS N I Main Street I Manteca 95336 505 Street Number Direction zip 95692-1025 Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4 5 6 7 Enterprise Street Quik Stop Markets, Inc. Street Number Street Name CITY STATE ZIP Manteca CA 95336 PHONE #1 ExT. ( ) APN # SE APPLICATION # PBOS PHONE #2 ExT ISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A�(MENT CHECK if BILLING ADDRESS Veronica Freitas ACCEPTED BY: 1 , V1 EMPLOYEE #: BUSINESS NAME DATE: PHONE # ExT. Walton Engineering, Inc. DATE: (916)373-1167 SERVICE CODE: t 8 HOME or MAILING ADDRESS Fee Amount: S FAX # P.O. Box 1025 Payment Type (916)373-1172 CITY West Sacramento STATE CA zip 95692-1025 BILLING ACKNOWLEDGEMENT: 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, Standard , STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 6/29/12 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor IfAPPL[CANT 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:Ip A�(MENT COMMENTS: R JUL - 5 2012 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: 1 , V1 EMPLOYEE #: DATE: ASSIGNED TO: `Q U EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: t 8 P I E: 140& Fee Amount: S Amount Paid �� . �, Paymen Date -71 1 G- Payment Type Invoice # Check # 'S-3 Z: Received By: � EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003