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SAN JOA0000UNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID #I <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />_ <br />T ����% � � 7 <br />�c—, t &��� <br />Gas Station <br />((� <br />OWNER /OPERATOR <br />HOME or MAILING ADDRESS <br />Quik Stop Markets <br />P.O. Box 1025 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY West Sacramento <br />STATE CA ZIP 95620 <br />Quik Stop #39 <br />EMPLOYEE #: <br />DATE: I _ <br />SITE ADDRESS 2285 <br />E <br />Fremont <br />I <br />P 1 E: <br />Fee Amount: l I 00 <br />Stockton <br />95205 <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />I Receiv d By: <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />4567 <br />Enterprise St. <br />Street Number <br />Street Name <br />CITY <br />STATE <br />Zip <br />Fremont <br />CA 94538 <br />PHONE #1 Ex -r. <br />APN # ' I I <br />G <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />E] <br />Veronica Freitas <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />X04 <br />PHONE# ExT. <br />Walton Engineering, Inc. <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />FAX # <br />P.O. Box 1025 <br />ACCEPTED BY: <br />(916)373-1173 <br />CITY West Sacramento <br />STATE CA ZIP 95620 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />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, Standards, STATE <br />�� and FEDERAL laws. <br />ff <br />APPLICANT'S SIGNATURE: A`-' DATE: 11/29/16 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT [3 Contractor <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. .11 <br />TYPE OF SERVICE REQUESTED: j Q 1 <br />COMMENTS: <br />X04 <br />;y F <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: l l <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: I _ <br />Date Service Completed (if already completed): <br />SERVICE CODE:' <br />P 1 E: <br />Fee Amount: l I 00 <br />Amount Paid �f/7, <br />Payment Date <br />l 3 <br />Payment Type <br />Invoice # <br />Check # '5/�M' <br />I Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />