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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTI&PARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel FACILITY ID # 643 CHECK if BILLING ADDRESS❑ SERVICE REQUEST # 5r-Qo& ,/4�3 `7t"" -L OWNER /OPERATOR Pacific Convenience and Fuels, LLC CHECK If BILLING ADDRESS❑ FACILITY NAME CRLLC #2705446 HOME or MAILING ADDRESS P.O. Box 1025 EMPLOYEE #: CJS Q S`� SITE ADDRESS 1403 Street Number Direction Country I Club Blvd. Street Name Stoc ton city 95204 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number SERVICE CODE: Street Name CITY Fee Amount: 75 STATE ZIP PHONE #1 EXT. APN # Payment Type �� LAND USE APPLICATION # PHONE #2 EXT. ( ) Check # Lt (k BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan - Compliance Manager CHECK if BILLING ADDRESS❑ BUSINESS NAME Walton Engineering, Inc. PHONE# 91q EXT• 373-1166 HOME or MAILING ADDRESS P.O. Box 1025 EMPLOYEE #: CJS Q S`� FAx# ( 91F 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:_ DATE: 3 — 6 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L"1 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. 0AVKJ1mK r TYPE OF SERVICE REQUESTED: U's / RECEIVED COMMENTS: e) MAR 2 2012 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: % � C/ EMPLOYEE #: CJS Q S`� DATE: 2-3 h.2— ASSIGNED TO: r� � Lj_ EMPLOYEE #: c/ G3/ DATE: Date Service Completed (if already completed): SERVICE CODE: % PIE: 3 CJ Fee Amount: 75 Amount Paid '? - J Payment Date Payment Type �� Invoice # Check # Lt (k Received By: 1 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003