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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH WARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # the 91 STP Sump, UDC # 1/2, #7/8, and #9/10. in presence of Inspector with reports. PHONE# 916 EXT' 373-1152 HOME or MAILING ADDRESS P.O. BOX 1025 OWNER / OPERATOR FAX # (916) Convenience Retailers, LLC. /Pacific Conv. & Fuels CHECK If BILLING ADDRESS FACILITY NAME CRLLC #2705447 ZIP 95691 SITEADDRESS 1469 East Hammer Lane Stockton 95210 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2603 Camino Ramon, Suite 350 Received By: 2� Street Number Street Name CITY San Ramon STATE CA ZIP 94583 PHONE #1 EXT• APN # LAND USE APPLICATION # (925) 884 - 0827 PHONE #2 EXT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Michael Walton CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. the 91 STP Sump, UDC # 1/2, #7/8, and #9/10. in presence of Inspector with reports. PHONE# 916 EXT' 373-1152 HOME or MAILING ADDRESS P.O. BOX 1025 DATE: FAX # (916) 373-1173 CITY West Sacramento STATE CA ZIP 95691 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, ST PAYMENT JRECEIVED02 - 22 -11 APPLICANT'S SIGNATURE: DATE: VEB 11 2011 PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILL/NG PARTY, proof of authorization to sign is required Title SAN JOAQUIN COUNTY ENVIRONMENTAL AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property 1�R TMENT 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: I4 S / COMMENTS: Secondary Repairs to Perform final testing the 91 STP Sump, UDC # 1/2, #7/8, and #9/10. in presence of Inspector with reports. ACCEPTED BY: EMPLOYEE M (i�S «[ DATE: ASSIGNED TO: % EMPLOYEE M �� ' DATE: Date Service Completed (if already completed): SERVICE CODE: % C. (� Fee Amount: 3 (o(o O D Amount Paid 14 Lr) p Payment Date D-3 I Payment Type 77-7Invoice # Check # �3 E�j Received By: 2� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003