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Y ' <br /> SAN JOAQUO;OUNTY ENVIE:ONMFtNTAL HEALT&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ceqk SW o 6 oSCL5" <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc . CHECK If BILLING ADDRESS <br /> FACILITY NAME Quik Stop # 121 <br /> SITE ADDRESS 1196 West Louise Avenue Manteca T95336 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Fremont CA 94538 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 510) 657-8500 <br /> PHONE R En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( C L— PHONE# ExT' <br /> Walton Engineering, Inc . J I Ji—, 916 373-1165 <br /> HOME or MAILING ADDRESS A t I r 2 ,!�t L U 1 u FAX# <br /> P.O. Box 1025 t1 (916 )373-1173 <br /> CITY West Sacramento E( VIKUNIl ItA l' HAMO CA ZIP 95691 <br /> rcniBILLING ACKNOWLEDGEMENT: I, the undersigned property or us ness r, 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, TAand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> 3,and <br /> �---� DATE: S'23 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 19 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmentaUsit assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thee it is <br /> provided to me or my representative. Fc <br /> TYPE OF SERVICE REQUESTED: f ° r— <br /> COMMENTS: /y F �Uq � <br /> This facility is upgrading its POS equipment . This requ",o,`N <br /> monitoring system "cold-start" to ensure proper communicatio-V,;qZ q��vTy <br /> A Monitoring System Certification will be performed and submitte�NT <br /> to the Owner and the Agency (including alarm history) . <br /> ACCEPTED BY: 0Li%.J,5 '44 I <br /> EMPLOYEE M 7 2 4 DATE: �G C 01 <br /> ASSIGNED TO: EMPLOYEE M Z(,,:f(f. DATE: M>-'( <br /> -' I <br /> Date Service Completed (if already completed): SERVICE CODE: 14� P 1 E: 2-3 d g <br /> Fee Amount:it , ,i,( CM/J Amount Paid 3 b Payment Date �12411 p <br /> Payment Type ✓ Invoice# Check# '3 o `j U Received By: (,qTT <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />