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0 4 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Dispensing Facility <br />ACCEPTED BY: A /1 ^ <br />!, I ' <br />CHECKIf BILLING ADDRESS <br />S2ao (o 9 473 <br />DATE: <br />l <br />PHONE# <br />916 <br />EXT• <br />373-1165 <br />HOME or MAILING ADDRESSP <br />P.O. BOX 1025 <br />OWNER/OPERATOR <br />FAX # <br />(916) <br />Flyers Energy, I,I,C <br />CHECK if BILLING ADDRESS <br />FACfUTY NAME Flyers #427 <br />ZIP 95691 <br />SITE ADDRESS 3300 <br />A3 7S <br />Waterloo <br />—T— <br />Stockton <br />95205 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I <br />2360 Street Number <br />Lindbergh Street Name <br />CITY Auburn <br />STATE CA ZIP 95602 <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(530) 885-0401 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />PAYMENT <br />COMMENTS: <br />Angel Rodriguez <br />ACCEPTED BY: A /1 ^ <br />!, I ' <br />CHECKIf BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />g g, <br />DATE: <br />l <br />PHONE# <br />916 <br />EXT• <br />373-1165 <br />HOME or MAILING ADDRESSP <br />P.O. BOX 1025 <br />DATE: <br />FAX # <br />(916) <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />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, STAT d FEDERAL laws. JJ <br />APPLICANT'S SIGNATURE: DATE: I I / 7 f _S <br />PROPERTY / BUSINESS OWNER ❑ OP AT R / MANAGER ❑ OTHER AUTHORIZED AGENT ® 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 to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: �� <br />PAYMENT <br />COMMENTS: <br />RECEIVED <br />NOV 12 2013 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: A /1 ^ <br />!, I ' <br />EMPLOYEE #: 76-70 <br />DATE: <br />l <br />ASSIGNED TO: / <br />EMPLOYEE #: <br />DATE: <br />Date Service Com ted (if alreado completed): <br />SERVICE CODE: <br />PIE: l Zr U <br />Fee Amount: 37- - <br />I Amount Paid <br />A3 7S <br />Payment Date <br />Payment Type (fi .o'!ec <br />Invoice # <br />Check # LY /0�3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 � � , <br />