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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTISPARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel FACILITY ID # CHECK if BILLING ADDRESSO SERVICE REQUEST # �lctx) X710 '' OWNER/ OPERATOR Quik Stop Market, Inc. P§PTq CHECK if BILLING ADDRESS FACILITY NAT! Stop #125 FEB 16 2011 FAX# 016) SITE ADDRESS 1580 Street Number W Direction Main Street Street Name ENVIRONMENTAL HEALTH DEPARTMENT Ripon city 95366 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number EMPLOYEE #: �ry / Gr Street Name CITY STATE ZIP PHONE #1 ExT. ( 519 657-8500 APN # Fee Amount: LAND USE APPLICATION # PHONE #Z ExT. ( ) Payment Date BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan CHECK if BILLING ADDRESSO BUSINESS NAME Walton Engineering, Inc. P§PTq 373-1166 EXT. HOME or MAILING ADDRESS P.O. Box 1025 FEB 16 2011 FAX# 016) 373-1173 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATUREc e^ - DATE: � PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER [IL? OTHER AUTHORIZED AGENT Compliance Manager If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 14-t Lt_. COMMENTS: R E C E iV E D FEB 16 2011 &kN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: Ci o j- 7 3 DATE: ASSIGNED TO: EMPLOYEE #: �ry / Gr DATE: ":2 Date Service Completed (if already completed): SERVICE CODE: q P I E: 365 Fee Amount: Amount Paid 3 (o Payment Date I -P b Payment Type Invoice # Check # Lk3 ':�7 `131 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003