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19I <br /> �-� + NVIRON MENTAL HEALTH DEPARTMENT <br /> 9 N JOAQUIN COUNTY Ti <br /> SERVICE REQUEST <br /> P FACILITY ID # SERVICE REQUEST # <br /> b �iness or' Property , WfA W 45, <br /> DCOO Cf <br /> Gas Station <br /> CHECK If BILLING ADD ❑ <br /> RESS <br /> OWNER I OPERATOR <br /> FACILITY NAME Colonial Ener #40138 <br /> Hi hwa 88 Lockeford 95237 <br /> SITE ADDRESS 14000 E g y c l z code <br /> et <br /> Street Number Direclio t 6 ame <br /> 2860 N . Santiago Blvd . <br /> HOME or MAILING ADDRESS (If Different from Site Address) streol a e <br /> SlreeI Number ZIP <br /> STATE CA 95237 <br /> CITY Lockeford • <br /> ExT. APN # LAND USE APPLICATION # <br /> PHONE #1 <br /> ( 916 ) 285 -7402 LOCATION CODE <br /> Exr. BOS DISTRICT <br /> PHONE #2 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> CHECK If BILLIN�ESS <br /> FBUSINEss <br /> OR ]EI <br /> Veronica Freitas EXT* <br /> PHONE # <br /> NAME Walton Engineering, Inc . 916 373 - 1166FAx # <br /> AILING ADDRESS P Box 1025 ( 916 ) 373 - ]. L `71 <br /> STATE CA ZIP <br /> CITY West Sacramento 9q691 <br /> BILLING ACKNOW ead o undersigned operator itent f <br /> acknowledge that all site specific ENVIRONMENTAL HEALTH DEPARTMENT hourlycharges associated with this project <br /> or activity will be billed to me or my business as identified on this form . <br /> 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 <br /> COUNTY Ordinance Codes, Slandards, /TATE and FEDERAL I s • 1 7R <br /> APPLICANT' S SIGNATURE : G .,(� DATE : <br /> PROPERTY / BUSINESS OWNER 13 <br /> OPERATOR / NOTANAGER 13OTHER AUTHORIZED AGENT IM Contractor <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZd at the <br /> ATION TO RELEASE INFORMATION : When applicable, 1 , the ownete or opei chnical data and/or environmental/site q of tile property assessment <br /> above site address, hereby authorize the release of any and all results, g <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at@�p Sa►ne time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN �Ogy o 9 ?019 <br /> El1/�j QUI/yC <br /> N U <br /> Nary ie NA4 <br /> i <br /> EMPLOYEE #: 1 DATE: <br /> ACCEPTED BY: i � � <br /> EMPLOYEE #: DATE: s— � _I <br /> ASSIGNED TO: 2 _ r PIE@ <br /> SERVICE CODE: <br /> Date Service Completed ( if already completed) : <br /> Amount Paid Payment Date �d <br /> Fee Amount: Received By : <br /> Payment Type <br /> Invoice # Check # 5 q <br /> C ) n�� � � SR FORM (Golden Rod) <br /> EHD4 &02-025 �Jr°rl�o` 0` Y�S <br /> REVISED 11 /17/2003 <br />