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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER/ OPERATOR Pacific Convenience and Fuels, LLC CHECK If BILLING ADDRESS FACILITY NAME CRLLC #2705446 Walton Engineering, Inc. EMPLOYEE #: 7 ` v SITEADDRESS 1403 Street Number I Direction Country I Club Blvd. Street Name P.O. Box 1025 Stockton city 95204 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number West Sacramento Street Name CITY Fee Amount: 71 —� STATE ZIP PHONE #1 EXT. l ) APN # Payment Type Invoice # LAND USE APPLICATION # PHONE #2 EXT. l ) Received By: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Veronica Freitas COMMENTS: 1 BUSINESS NAME �r PHONE# EXT' Walton Engineering, Inc. EMPLOYEE #: 7 ` v 916 - (916)37,1-11-67 HOME or MAILING ADDRESS HOME ASSIGNED TO: �1 . L� L ? FAX# P.O. Box 1025 (916)373-1162 CITY STATE ZIP West Sacramento { 11 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. t APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® contractor IfAPPLICANT 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: ('i S' R EIZ W COMMENTS: 1 �r ACCEPTED BY: �' �! V EMPLOYEE #: 7 ` v DATE: S 2 t 2 J ASSIGNED TO: �1 . L� L ? EMPLOYEE #:Ga G ''3 DATE: �2 Date Service Completed (if already completed): SERVICE CODE: { 11 P/6: ,�� O u Fee Amount: 71 —� Amount Pai 375oD Payment Date Z /.3 Payment Type Invoice # Check # 'i(o5 73 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003