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SAN JOA0000UNTY ENVIRONMENTAL HEALT PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rviEFCEIVeD <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />106en <br />6AW &'?X145' - <br />OWNER /OPERATOR <br />CHECK <br />Quik Stop Markets, Inc. <br />if BILLING ADDRESSO <br />FACILITY NAME <br />P.O. Box 1025 <br />Quik Stop #76 <br />(916 ) 373-1173 <br />SITE ADDRESS 1030S <br />STATE CA zip 95691 <br />Olive Ave. <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />Fee Amount: 3 76� oo <br />Cit <br />z1g) <br />HOME or MAILING ADDRESS (If Different from Site Address) 4567 <br />Invoice # <br />Enterprise Street <br />L <br />Street Number <br />Street Name <br />CITY Fremont <br />STATE CA ZIP <br />94538 <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rviEFCEIVeD <br />Veronica Freitas <br />CHECKif BILLING ADDRESS® <br />BUSINESS NAME <br />Walton Engineering, Inc. <br />PHONE# EXT• <br />',G <br />ENVlR�H4f COL, <br />EAO?, <br />42 <br />916 373-1167 <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: / <br />FAX # <br />P.O. Box 1025 <br />(916 ) 373-1173 <br />CITY West Sacramento <br />STATE CA zip 95691 <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: <br />DATE: 4/12/14 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 13 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 t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 61.5 r � T�%j 7— <br />rviEFCEIVeD <br />COMMENTS: <br />�� ' 2014 <br />',G <br />ENVlR�H4f COL, <br />EAO?, <br />42 <br />ACCEPTED BY: / <br />EMPLOYEE #: & C/ <br />DATE: <br />ASSIGNED TO: j�Z%(f�j�r <br />EMPLOYEE #:/!� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PI E: 3C� <br />Fee Amount: 3 76� oo <br />Amount PaIY3 7S OQ <br />Payment Date <br />1 <br />Payment Type <br />Invoice # <br />Check # 47F'77 <br />Received By. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />