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SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTH OARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Veronica Freitas SERVICE REQUEST # Gas StationNi O a 36" aD (O W),�. OWNER /OPERATOR CHECK If Flyers Energy, LLC. BILLING ADDRESS FACILITY NAME P.O. Box 1025 Olympian Fl ers #427 (916)373-1173 SITE ADDRESS STATE CA ZIP 95691 Fee Amount: 3-7f _____� Amount Paid 375 U D Payment Date 3300 I Waterloo Road I Stockton 95205 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2360 Lindbergh Street Street Number Street Name CITY Auburn STATE CA ZIP 95602 PHONE #1 ExT• APN # LAND USE APPLICATION # PHONE #2 Exr. BOS DISTRICT LOCATION CODE ( ) 0 0 L c1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Veronica Freitas CHECK If BILLING ADDRESS® BUSINESS NAME ACCEPTED BY: I� ° PHONE # ExT. Walton Engineering, Inc. DATE:j- G '/ (916)373-1167 HOME or MAILING ADDRESS EMPLOYEE #: Lq ZLDATE: FAX # P.O. Box 1025 (916)373-1173 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: 1, 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:A.-le-DATE: 02/11/2014 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT El 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 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: COMMENTS: LJBB &48 'OAQIj 2014 N CO ACCEPTED BY: I� ° EMPLOYEE #:-7 DATE:j- G '/ ASSIGNED TO: // EMPLOYEE #: Lq ZLDATE: Date Service Completed (if alrea y ompleted): SERVICE CODE: Fee Amount: 3-7f _____� Amount Paid 375 U D Payment Date 2 Payment Type Invoice # Check # L�73 Received By: EHD 48-02-025 07/17/08 (e c ary SR FORM (Golden Rod)