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SAN JOAJIN COUNTY ENVIRONMENTAL HEALTREPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# Veronica Freitas SERVICE REQU�EST # BUSINESS NAME r 43 PHONE # ExT. 64- L � T l (' Retail as station v HOME or MAILING ADDRESS OWNER/ OPERATOR P.O. Box 1025 Pocific Convenience anti Fuelq, 11C CHECK If BILLING ADDRESS FACILITY NAME CRT I C *5446 STATE CA ZIP 95691 SITE ADDRESS 1403Country Date Service Completed (if already completed): Club Blvd SERVICE CODE: /'3 % Stockton 95204 Street Number Direction Street Name Payment Type V i S14 City Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 7108 I i�eceiveBy: 42-1 Koll Center Pkwy, Ste 100 Street Number Street Name CITY Pleasanton STATE CA ZIP 94566 PHONE #1 ExT. ( ) APN # LAND USE APPLICATION # PHONE #2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR if BILLING ADDRESS Veronica Freitas CHECK BUSINESS NAME NOV 15 201(3) PHONE # ExT. Walton Engineering, Inc. 916 373-1167 HOME or MAILING ADDRESS FAX # P.O. Box 1025 (916)37-3-117-3 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. 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: 11/14/2013 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 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 t0 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: Lk C) COMMENTS: R66EIVE^ NOV 15 201(3) SAN JOAQUIN COUNTY ENVIROMENTAL ACCEPTED BY: G EMPLOYEE #: DATE: �1 ^ /T^ 13 ASSIGNED TO: (] EMPLOYEE #: DATE: / _ 14 - 4_Date Date Service Completed (if already completed): SERVICE CODE: /'3 % PIE: !/-7 -) Fee Amount: �' 2 5-0 &ZL-54 Amount Paid — . _ D Payment Date 1111,5-11n; I Payment Type V i S14 1 Invoice # Check # I i�eceiveBy: 42-1 EHD 48-02-025 07/17/08 SR FORM (Golden Rod)