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SAN JOAQUIiR;OUNTY ENVIRONMENTAL HEALTHIRPARTMENT SERVICE REQUEST Type of Business or Property gas station FACILITY ID # MIDb q!4 X SERVICE REQUEST # 09!��46—� OWNER/ OPERATOR Pacific Convenience and Fuels, LLC CHECK If BILLING ADDRESS FACILITY NAME CRLLC #2705446 DATE: PHONE # SITEADDRESS 1403 Street Number I Direction Country Club Blvd. I Street Name (916)373-1167 Stockton city 95204 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street NumberT Fee Amount: l/D hf? -� 7Sr Street Name CITY (916)373-1173 STATE ZIP PHONE #1 ExT. ( ) APN # LAND USE APPLICATION # PHONE #2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR PAYMENT X Veronica Freitas ACCEPTED BY: CHECK If BILLING ADDRESS BUSINESS NAME DATE: PHONE # ExT. Walton Engineering, Inc. DATE: (916)373-1167 SERVICE CODE: HOME or MAILING ADDRESS FAX # Fee Amount: l/D hf? -� 7Sr P.O. Box 1025 Paymen (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, TE and FEDERAL laws. r APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® contractor 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: PAYMENT COMMENTS: AUG 2 7 2012 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: P i E: Ji Fee Amount: l/D hf? -� 7Sr Amount Paid 3� S p "� Paymen Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003