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SAN JOAQU00UNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> Retail Fuel �SS� <br /> OWNER/OPERATOR <br /> Quik Stop Market, Inc . CHECK If BILLINGADDRESSO <br /> FACILITY NAMikE <br /> Qu Stop #120 <br /> SITE ADDRESS 9321 Thornton Road Stockton 95209 <br /> Street Number Direction I Street Name 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 Exr. APN# LAND USE APPLICATION# <br /> ( 519 657-8500 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . PSV 373-1166 Exr. <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 1025 016 ) 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: S <br /> tv <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT UP 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. <br /> TYPE OF SERVICE REQUESTED: 7 _ PAYMENT <br /> COMMENTS: RECEIVED <br /> MAY 31 20:11 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I EMPLOYEE#: 6� DATE: — '31 /f/ <br /> ASSIGNED TO: EMPLOYEE#: [� y DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: i Pl P 1 E: -2-30-4 <br /> Fee Amount: Amount Paid ' _�� Payment Date �/ <br /> Payment Type Invoice# Check# If Lf 1 i, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />