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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RushSERVICE REQUEST ype of Business or Property FACILITY ID # SERVICE REQUEST # Retail Gas Station �Ooc 1 O SI -L Z� V %S J OWNER /OPERATOR CHECK if BILLINGADDRESS❑ Quik Stop Markets, Inc. BUSINESS NAME Walton Engineering, Inc. FACILITY NAME PHONE # Quik Sto #076 ACCEPTEDBY: SITE ADDRESS 1030 $ Olive Ave. HOME or MAILING ADDRESS Stockton 95215 Street Number Direction t Na (916) Ci Zi Cod e HOME Or MAILING ADDRESS (If Different from Site Address) ZIP 95691 Received By: m Street Number Street Name CITY STATE ZIP PHONE #1 ExT• ( ) APN # LAND USE APPLICATION # PHONE #2 Exr• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR COMMENTS: Veronica )Freitas CHECK If BILLING ADDRESS® BUSINESS NAME Walton Engineering, Inc. SAN JOAQUIN COUNTY 1EN"0 ENTAL PHONE # ExT• ACCEPTEDBY: EMPLOYEE#: �� U r 91 373-1167 HOME or MAILING ADDRESS DATE:LLI FAx # SERVICE CODE: I C1 C1 P.O. Box 1025 Fee Amount: Amount Paid (916) 373-1173 Cm West Sacramento STATE CA ZIP 95691 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 TATE and FIE ERAL 18WS. APPLICANT'S SIGNATURE: DATE: _0 7 -1 _ - 3 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AuTHORizED AGENT ®_conte r nr 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 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: S COMMENTS: JUL 1 6 ?b 3 SAN JOAQUIN COUNTY 1EN"0 ENTAL HEALTH ARTMENT ACCEPTEDBY: EMPLOYEE#: �� U r DATE: 7116 ' 3 �+ ASSIGNED TO: j f EMPLOYEE #: DATE:LLI Date Service Compl d (if already CO leted): SERVICE CODE: I C1 C1 PIE: L Fee Amount: Amount Paid 37S Payment Date Payment Type ✓ Invoice # heck # Received By: m ,,L- V I5� EHD 48.02-025 07/17/08 I ,2 � nF " o Iz ! 37 SR FORM (Golden Rod)