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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Station <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop x#076 <br /> SITE ADDRESS 1030S Olive Ave. Stockton 95215 <br /> Street Number Dire Street Name ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street.Number Street Name <br /> CITY STATE ZIP <br /> PHONE#•1 ExT• APN# LAND USE APPLICATION# <br /> I I <br /> PHONEZT• SOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS <br /> ED <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc . 91 373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916) 373-1173 <br /> CITY West Sacramento STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 <br /> COUNTY Ordinance Codes,Standard.1 TATE andERAL la r <br /> APPLICANT'S SIGNATURE: �,X :-; ' <br /> DATE:_D 7-12-13 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C•o rA rt--n . <br /> If APPLIGANris not the BILLING PARTY.proof of authorization to sign is required Titre <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 is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# 71 Received By: <br /> EHD 48-02-025 <br /> 07117108 SR FORM(Golden Rad) <br />