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SAN JOAQUIN6OUNTY ENVIRONMENTAL HEALTI�EPARTMENT SERVICE F:EQUEST Type of Business or Property Retail Fuel I^%— FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR Quik Stop Market, Inc. CHECK if BILLING ADDRESS❑ FACILITY NAME Quit{ Stop #144 HOME or MAILING ADDRESS P.O. Box 1025 U I SITE ADDRESS 7272 Street Number I Direction West Lane I Street Name STATE CA Stockton 95210 ZID Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number EMPLOYEE M D Street Name CITY STATE AUG IP6 20on PHONE #1 EXT. (510) 657-8500 P / E: ' APN # of -"4 OLto—r3 LAND USE A @LAMENT HEALTH PERMITSE PHONE R EXT. 7J� S BOS DISTRICT LOCATpN CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Webb I^%— CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. PHONE# 916 ExT. 373-1166 HOME or MAILING ADDRESS P.O. Box 1025 U I FAX # (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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:_ L� DATE: o9 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L? Compliance Manager If APPLICANT is not the BILLING PARTY. proof Of authorization to sigh 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 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. , � n G NT TYPE OF SERVICE REQUESTED: (,(_S 1 -Z7 I^%— ID CeM COMMENTS: rt �OQg Aug 1 CpuNN JOAQ 4 TPL H�►.TN p P RTMEI�IT ACCEPTED BY: U I EMPLOYEE #: DATE: e Z? U 9 ASSIGNED TO: � � EMPLOYEE M DATE: '/ Z7 0 C Date Service Completed (if already completed): SERVICE CODE: / Q P / E: ' Fee Amount: 0 Amount Paid 7J� S Payment Date 21 Payment Type S Invoice # Check # ` � � 1 3 q � � d d Receive By: EHD 48-02-025 1 1 `Oq �l SR FORM (Golden Rod) REVISED 11/17/2003 3 L45 .Uu