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SAN JOAQU%OUNTY ENVIRONMENTAL HEALTWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (PC' `54400 l008�� <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc . CHECK if BILLING ADDRESS <br /> FACILITY NAME Quik Stop # 125 <br /> SITE ADDRESS 1580 West Main Street Ripon 95366 <br /> Street Number I Direction I Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY Fremont STATE CA ZIP 94538 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 510) 657-8500 <br /> PHONE#Z EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr <br /> I CHECK if BILLING ADDRESS <br /> BUSINESS NAME — —' PHONE# EXT. <br /> Walton Engineering, Inc. r , 916 373-1165 <br /> HOME or MAILING ADDRESS AYG FAX# <br /> P.O. Box 1025 1 NIVIt-N HEA' (916 )373-1173 <br /> CITY West Sacramento PERNAIT/SE 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,S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ���� G�tv DATE: 'ZAy <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® &07Y0(k <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 saQ IyI �it is <br /> provided to me or my representative. /J ��C,'VJ.l1/T <br /> TYPE OF SERVICE REQUESTED: (�_S 7-- <br /> � I2—jr-� r-c� 'q OG <br /> COMMENTS: I N JO <br /> This facility is upgrading its POS equipment . This requi, 1// oL11NO <br /> monitoring system "cold-start" to ensure proper communications PgRq�N <br /> A Monitoring System Certification will be performed and submitted FN <br /> to the Owner and the Agency (including alarm history) . <br /> ACCEPTED BY: 0c, EL ./� + EMPLOYEE#: DATE: fv <br /> ASSIGNED TO: 444-( 6 u —^T EMPLOYEE#: ��-7 DATE: g- Z;,(/1/0 <br /> Date Service Completed (if already completed): SERVICE CODE: (c�dY PIE: d�- <br /> Fee Amount: Amount Paid 3 (p Payment Date Z(2 t 1// v <br /> Payment Type Invoice# Check# 4 3 O ✓I Received By: Vy�,- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />