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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT119PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> as station _r4DO006N-1 d 66 2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Quik Stop Markets Inc. <br /> FACILITY NAME Quik Stop #12S <br /> SITE ADDRESS 1580W Main Street Ripon 95366 <br /> Street Number Din3ction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4 5 6 7 Enterprise Street <br /> Quik Stop Markets, Inc . Street Number Street Name <br /> CITY STATE ZIP <br /> Fremont CA 94538 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK If BILLING ADDRESS X <br /> BUSINESS NAME PHONE# ExT' <br /> Walton Engineering, Inc. (916) 373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 102S (916) 3 73-1172 <br /> CITY West Sacramento STATE CA Zip 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/7/12 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® r•an t ra r t a r <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5-�r4 rmr <br /> COMMENTS: <br /> ACCEPTED BY: 6mg <br /> EMPLOYEE#: DATE: .L <br /> ASSIGNED TO: 1 , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): v SERVICE CODE: P 1 E: O <br /> Fee Amount: ?� S Amount Paid 3'Z�j Qv Payme t Date / /D `Z <br /> Payment Type Invoice# Check# 45-7/3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />