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SAN JOAQUI16OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUfESST# <br /> GDF � V SPOC) � '[OL <br /> OWNER/OPERATOR <br /> Convenience Retailers, LLC./Pacific Conv. & Fuels CHECK If BILLINGADDRESS� <br /> FACILITY NAME CRLLC #2705447 <br /> SITEADDRESS 1469 East Hammer Lane Stockton 95210 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2 603 Camino Ramon, Suite 350 <br /> Street Number Street Name <br /> CITY San Ramon STATE CA Zip 94583 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (925) 884-0827 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Michael Walton <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916 373-1152 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. BOX 1025 <br /> (916) 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,ST j/ <br /> ` <br /> APPLICANT'S SIGNATURE: DATE: 05-02-12 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Replace the direct bury 91 spill container with a like-fob <br /> ONA <br /> OPW 2100 series SC. The existing SC has not failed, thdamh Ja <br /> q <br /> concrete needs repairs. <br /> ACCEPTED BY: EMPLOYEE#: DATE:e <br /> ASSIGNED TO: EMPLOYEE#: 6 DATE: <br /> Date Service Comp ed (I already completed): SERVICE CODE: /95;/ <br /> P I <br /> a <br /> Fee Amount: S �Sv Amount Paid — Payment Date L7 <br /> Payment Type Invoice# Check# (i Receive By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />