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• SAN JOAQU*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P R 00 <br /> OWNER/OPERATOR <br /> Convenience Retailers, LLC./Pacific Conv. & Fuels CHECK If BILLING ADDRESS <br /> FACILITY NAME CRLLC #2705446 <br /> SITEADDRESS 1403 Country Club Blvd. Stockton 95204 <br /> Street Number I Direction Street NameCi Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2603 Camino Ramon, Suite 350 <br /> Street Number Street Name <br /> CITY San Ramon STATE CA ZIP 94583 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (925) 884-0827 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Michael Walton CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> Walton Engineering, Inc. 916 373-1152 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. BOX 1025 <br /> (916) 3763-1173 <br /> CITY West Sacramento STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applicationand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ani FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 5- - (3 - (0 <br /> / - (3 — (O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AA AGER OTHER AUTHORIZED AGENT® C,I.,Ai I XA(.It i2 <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 1 ` <br /> TYPE OF SERVICE REQUESTED: / <br /> COMMENTS: Replace the failed 87 direct b ry spill container. Replace the <br /> corroded float chain components in the Disp #1/2 UDC. <br /> ACCEPTED Y: EMPLOYEE#: DAT--r4 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Iq <br /> Date Service Completed (if already completed): SERVICE CODE: t P 1 E:` 5 Q <br /> Fee Amount: Amount Paid 3(A s Payment Date s I (v <br /> Payment Type ✓ Invoice# Check# L. Lli Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />