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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel 03 y <br /> ,d; l f <br /> OWNER/OPERATOR n `' y `' CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME CRLLC #2705447 2 <br /> SITE ADDRESS 1469 E Hammer LaneStoc ton <br /> w= ��F! 95210 <br /> Street Number Direction I Street Nam city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan - Compliance Manager CHECK If BILLING ADDRESS <br /> BUSINEss NAME Walton Engineering, Inc . PHONE# ExT. <br /> 91q 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 91q 373-1173 <br /> CITY West Sacramento STATE CA ZIP 95691 <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 <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ — DATE: <br /> PROPERTY/BUSINEss OWNER 13 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT Compliance Manager <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. cc <br /> TYPE OF SERVICE REQUESTED: LtS T- A-f IZT <br /> COMMENTS: RC CE�V E <br /> p�T 2 6 2011 <br /> SAN ENVIR JOAQUIN W NT <br /> DEPAA <br /> ACCEPTED BY: 1_l Et /� EMPLOYEE M 3-L+ DATE: 10 /(( <br /> ASSIGNED TO: pj,�Gl-c L� EMPLOYEE#: q_(,2 DATE: t2 l�r <br /> Date Service Completed (if already completed): SERVICE CODE: / 96 P 1 E: .230k) <br /> Fee Amount:f4 *A 75-. Amount Paid 3�5. DL Payment Date 10 ,2 1( <br /> Payment Type Invoice# Check# Cf4 SSS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />