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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME SERVICE REQUEST # Gas Station FN 6 0 3 6 M 15"0 & qpA�3 OWNER /OPERATOR CHECK if BILLING 0 Flyers Energy, LLC. ADDRESS FACILITY NAME (916)373-1173 Olympian Fl ers #427 STATE CA Zip 95691 SITEADDRESS 3300 _ EMPLOYEE#: 26,—to Waterloo Road ASSIGNED TO: Stockton 95205 Street Number Direction Street Name Date Service Completed (if already ompleted): Cit ode Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 2360 Fee Amount: Lindbergh Street Street Number Payment Date /By: Street Name CITY Auburn STATE CA Zip 95602 PHONE #1 EXT• APN # LAND USE APPLICATION # ( ) 1 y13 - I's -0 — 0 Z - PHONE #2 EXT• BOS DISTRICT LOCATION CODE ( ) (00�- 11 59 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Veronica Freitas CHECKU BILLING ADDRESS BUSINESS NAME PHONE# EXT• Walton Engineering, Inc.(916)373-1167 &4N,O'4Q1'N 2014 HOME or MAILING ADDRESS FAX# P.O. Sox 1025 (916)373-1173 CITY 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. 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: DATE: 02/11/2014 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 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 my representative, TYPE OF SERVICE REQUESTED:t9 PLC4,N% COMMENTS: r F81? , Z &4N,O'4Q1'N 2014 R�HF��D pMR �N7y ACCEPTED BY: 5 11`nei fl lel 'T _ EMPLOYEE#: 26,—to DATE: P `fes ASSIGNED TO: d unAEMPLOYEE #: �ijg DATE: Date Service Completed (if already ompleted): i4 SERVICE CODE: i GRi f (C5 PIE: Fee Amount: 3 7 Amount Paid 4—�S U D Payment Date /By: Payment Type Invoice # Check # [1 '7 -3 Received l - EHD 48-02-025 07/17/08 rf (2 c °7ry SR FORM (Golden Rod)