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SAN JOA01* COUNTY ENVIRONMENTAL HEALT&PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station 6 0 0 31 sri-Clb 7/ `7 OWNER /OPERATOR CHECK (916)373-1166 Flyers Energy, LLC if BILLING ADDRESS FACILITY NAME P.O. Box 1025 Flyers #487 CITY West Sacramento STATE CA ZIP 95620 SITE ADDRESS 983 7�MEA, Moffat Blvd. Manteca95336 Street Number Direction Street Name Cit ASSIGNED TO: �^/� ZIp Code HOME Or MAILING ADDRESS (If Different from Site Address) 2360 Lindbergh Street Date Service Completed (if alread' completed): Street Number Street Name P / E: CITY Aurburn STATE CA Zip 95602 PHONE #1 Exr. ( ) APN # LAND USE APPLICATION # Payment Type _ PHONE #T ExT• _� BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS® BUSINESS NAME COMMENTS: PHONE # ExT. Walton Engineering, Inc. (916)373-1166 HOME or MAILING ADDRESS FAX # P.O. Box 1025 ( )916 373-1171 CITY West Sacramento STATE CA ZIP 95620 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. 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: 02-11-15 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 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 my representative. e. TYPE OF SERVICE REQUESTED: Al COMMENTS: 2015 7�MEA, p R4RrME'r ACCEPTED BY: Y► 1 �A^ r• 1 EMPLOYEE#: DATE: ASSIGNED TO: �^/� . EMPLOYEE #: DATE: Date Service Completed (if alread' completed): SERVICE CODE: (9 P / E: Fee Amount: u Z 'j o Amount Paid 7ro, 6D Payment Date 2—//7 �S Payment Type _ Invoice --i--------- _� Check # .e) Received By: EHD 48-02-025 0 SR FORM (Golden Rod) 07/17/08