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SAN JOAQUI&OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property s^ RP&:v1zJ FACILITY ID # REQUEST # • GDF PHONE # 916 EXT' 373-1152 ��SEER�i-VICE OWNER/ OPERATOR FAX# (916) Convenience Retailers, LLC./Pacific C onv. & Fuels CHECK if BILLING ADDRESSO FACILITY NAME ZIP 95691 CRLLC #2705446 DATE: SITE ADDRESS 1403 I Country Club Boulevard I Stockton I 95204 Street Number Direction Street Name city Zio Code HOME or MAILING ADDRESS (If Different from Site Address) 2 603umber Camino Ramon, Suite 350 Invoice # Street N Street Name CIN STATE Zip San Ramon CA 94583 PHONE #1 ExT• APN # LAND USE APPLICATION # (925) 884-0827 PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Michael Walton s^ RP&:v1zJ CHECK If BILLING ADDRESS lull BUSINESS NAME Walton Engineering, Inc. COMMENTS: Repair the waste oil piping Investigate and make repairs relay. Re -test with reports PHONE # 916 EXT' 373-1152 HOME or MAILING ADDRESS P.O. BOX 1025 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 tp bq performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, Sl J/�// "`� APPLICANT'S SIGNATURE: 05-21-12 DATE; r PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ RE(' F I V F D If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title f W AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property03a a the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentalbkq peWOUNTY information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the_ &"* ENT provided to me or my representative. H TYPE OF SERVICE REQUESTED: s^ RP&:v1zJ COMMENTS: Repair the waste oil piping Investigate and make repairs relay. Re -test with reports IV sump sensor, like -for -like Ronan LS -3. as necessary to the diesel turbine to Owner and Agency. ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: fl t� EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P / E:� Fee Amount: OD Amount Paid 1$3-75'66 Payment Date Payment Type ✓ Invoice # Check # 57 7 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003