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SAN JOAQUROUNTY ENVIRONMENTAL HEALTH IWARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />s b 0 36 D O <br />-5, P, 0 0 6) `177 <br />OWNER /OPERATOR <br />CHECK <br />Flyers Energy, LLC. <br />if BILLING ADDRESS <br />FACILITY NAME <br />Olympian #427 <br />P.O. Box 1025 <br />SITE ADDRESS 3300 <br />I <br />Waterloo Road <br />I <br />Stockton <br />T95205 <br />Street Number <br />Direction <br />3%S �� <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2360 <br />Lindbergh Street <br />Received By: <br />Street Number <br />Street Name <br />CITY Auburn <br />STATE CA ZIP <br />95602 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z ExT. <br />BOS DISTRICT <br />2 <br />LOCATION CODE <br />1111 <br />( ) <br />0 0 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS D <br />Veronica Freitas <br />COMMENTS:// <br />BUSINESS NAME <br />PHONE# EXT. <br />Walton Engineering, Inc. <br />EMPLOYEE #: 26 '7 o <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />FAX # <br />P.O. Box 1025 <br />Date Service Completed (if already ompleted): <br />(916)373-1173 <br />CITY West Sacramento <br />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: DATE: 05/30/14 <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 />to 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:71 tA 51—REC <br />ENT <br />. <br />COMMENTS:// <br />JUN 04 2014 <br />HS N 0E 11 y, 1- , <br />ACCEPTED BY: <br />I <br />EMPLOYEE #: 26 '7 o <br />DATE: [// 1 V <br />v `r <br />ASSIGNED TO: <br />EMPLOYEE #: 1I (L Q d% <br />DATE: <br />Date Service Completed (if already ompleted): <br />SERVICE CODE: l Q <br />PIE: 7,30 g <br />Fee Amount: S <br />Amount Paid <br />3%S �� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 G <br />