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SAN JOAQUIWnUNTY ENVIRONMENTAL HEALTTAMIRPARTMENT SERVICE REQUEST Type of Business or Property COMMENTS: FACILITY ID # SERVICE REQUEST # Retail Fuel CHECK if BILLING ADDRESS® BUSINESS NAME DATE: OWNER/ OPERATOR EXT. Quik Stop Market, Inc. CHECK if BILLING ADDRESS® FACILITY NA QuiME Stop #144 373-1166 SITE ADDRESS 7272 I West I Lane [Stockton 95210 Street Number Direction CITY West Sacramento Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Exr. APN # LAND USE APPLICATION # (510) 657-8500 PHONE #2 Exr. BOS DISTRICT LOCATION CODE 7 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Webb COMMENTS: ACCEPTED BY: EMPLOYEE M DATE: CHECK if BILLING ADDRESS® BUSINESS NAME DATE: PHONE# EXT. Walton Engineering, Inc. Fee Amount: 916 373-1166 HOME Or MAILING ADDRESS Invoice # FAX # Received By: P.O. Box 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. 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: �j _ X,y DAVE:O �' ® j PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER 13OTHER AUTHORIZED AGENT O: Compliance Manager 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 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: ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already Completed): SERVICE CODE: P / E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003