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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ; 570 604,afe7 <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc . CHECK if BILLING ADDRESS <br /> FACILITY NAME Quik Stop # 144 <br /> SITE ADDRESS 7272 West Lane Stockton 95210 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY Fremont STATE CA Zip 94538 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 510) 657-8500 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR im <br /> CHECK if BILLING ADDRESS LOU <br /> BUSINESS NAMEPHONE# Em' <br /> Walton Engineering, 4itl, `J�� a 916 373-1165 <br /> HOME or MAILING ADDRESS AUG � � z 1 FAX# <br /> P.O. Box 1025 (916 )373-1173 <br /> CITYWest Sacrament `� IL �' - ` I ILt :r`II 'STATE CA 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,StandardsTSTEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 31fg <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <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 prope located t e <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaNi t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the`sa s <br /> provided to me or my representative. 7 ! 21 <br /> TYPE OF SERVICE REQUESTED: C tS T- gAm.inAQUIN COUNTY <br /> COMMENTS: ENV I RO T <br /> This facility is upgrading its POS equipment . This requireH DEPARTM N <br /> monitoring system "cold-start" to ensure proper communication. <br /> A Monitoring System Certification will be performed and submitted <br /> to the Owner and the Agency (including alarm history) . <br /> ACCEPTED BY: 0(_t V£/ � EMPLOYEE#: n Q DATE: 2 . <br /> ASSIGNED TO: �? u�` EMPLOYEE#: L�✓�3 6 DATE: d Ltt /0 <br /> Data Service Completed (if already completed): SERVICE CODE: 9 P 1 E: g3 U(? <br /> Fee Amount: 3&&.&A) Amount Paid S 6 i� Payment Date g/,2-tj I v <br /> Payment Type Invoice# Check# I.E L) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />