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SAN JOAA COUNTY ENVIRONMENTAL HEALTWPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station l-�W1 I �17t� <br /> OWNER/OPERATOR <br /> Flyers Energy, LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Flyers#487 <br /> SITE ADDRESS 983 Moffat Blvd. Manteca 95336 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2360 Lindbergh Street <br /> Street Number Street Name <br /> CITY Auburn STATE CA Zip <br /> 95602 <br /> PHONE#1 EXT• APN# <br /> ( ) LAND USE APPLICATION# <br /> )a 00� <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR t <br /> REQUESTOR <br /> Veronica Freitas CHECKIf BILLINGADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento STATE CA ZIP 95620 <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: &e". <br /> DATE: 03-25-15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � c 4�1n_FV;P. <br /> qip? <br /> Cc <br /> ACCEPTED BY: \V Lv� EMPLOYEE#: DATE: ` <br /> ASSIGNED TO: \k EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C Gig PIE: <br /> Fee Amount: J 1-1 Amount Pai 3�j0- DD Payment Date 3 ZLI�' <br /> Payment Type Invoice# Check# <br /> Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />