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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />SERVICE REQUEST # <br />'54-06)& 49 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME CRLLC #2705447 <br />EXT. <br />373-1166 <br />SITE ADDRESS 1469 <br />Street Number <br />E <br />Direction <br />Hammer <br />Lane <br />Street Name <br />Stockton <br />City <br />95210 <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT• <br />APN # <br />Fee Amount: C't= <br />LAND USE APPLICATION # <br />PHONE K EXT. <br />Payment Type <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan - Compliance Manager <br />CHECK if BILLING ADDRESS❑ <br />BUSINEss NAME Walton Engineering, Inc. <br />PHONE# <br />91q <br />EXT. <br />373-1166 <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />EMPLOYEE M �% <br />FAX# <br />( 91C <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />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 SIGNATURFy:.DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L} 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. _ ,vupES'T <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />C�" <br />EMPLOYEE M �% <br />DATE: s �( <br />ASSIGNED TO: 1i C �S <br />EMPLOYEE M r (p �� <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />C <br />PIE: �-2 36. <br />Fee Amount: C't= <br />Amount Paid '4,37S --C-0 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # L- L131F <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />