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SAN JOAQU&OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />��b�bd��� <br />SERVICE REQUEST # <br />-7 <br />OWNER i OPERATOR <br />Quik Stop Market, Inc. <br />CHECK if BILLING ADDRESSO <br />FACILITY NAT! <br />Stop #125 <br />373-1166 EXT. <br />SITE ADDRESS 1580W <br />Street Number <br />Direction <br />Main <br />Street <br />Street Name <br />Ripon <br />city <br />95366 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT• <br />( 519 657-8500 <br />APN # <br />SERVICE CODE: i �� <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Fee Amount: - ( 0C) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />CHECK If BILLING ADDRESS <br />BuslNEssNAME Walton Engineering, Inc. <br />COMMENTS: <br />P§Tt# <br />373-1166 EXT. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />ACCEPTED BY:��� <br />FAx # <br />016) <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />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: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT U Compliance Manager <br />If APPLICANT is not the BILLrNGPARTI 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: <br />:C: �'.. •, <br />i 1 3 pr "9 <br />t r: <br />ACCEPTED BY:��� <br />EMPLOYEE #: <br />�� <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: i �� <br />P 1 E: 3rp <br />t <br />Fee Amount: - ( 0C) <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />y �\. ✓ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />