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SAN JOAQUIoOUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICLI`REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel <br /> OWNER/OPERATOR <br /> Quik Stop Market, Inc . CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop #121 <br /> SITEAQ1% W Louise Ave . Manteca 95336 <br /> AQP <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 514 657-8500 <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan CHECK if BILLING ADDRESSO <br /> BUSINESS NAME Walton Engineering, Inc. PRV 373-1166 Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (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, and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �"— DATE <br /> �� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3 Compliance Manager <br /> IfAPPLIC.WT 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. p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: p <br /> ACCEPTED BY: EMPLOYEE M DATE: /f <br /> ASSIGNED TO: V EMPLOYEE#: DATE: (g ( <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: 3W <br /> Fee Amount: '3�(r ec Amount Paid Payment Date l <br /> Payment Type �/ Invoice# Check# L�Lk\k,. 3 Received y: <br /> EHD 48-02-025 SR FORM(Golden R ) <br /> REVISED 11/17/2003 ( tw <br /> ��ye <br />