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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTI&PARTMENT SERVICE REQUEST Type of Business or Property -::IFACILITY ID # SERVICE REQUEST # Underground Storage Tank CHECK if BILLING ADDRESS® 5 -coo (as"�-'`7 OWNER / OPERATOR PHONE # Quik Stop Markets Inc. CHECK If BILLING ADDRESS FACILITY NAME 916 Quik Sto"Dilti.. HOME or MAILING ADDRESS SITE ADDRESS FAX # Main Street P.O. Box 1025 Ripon 95366 1580 Street Numb CITY West Sacramento Street Name ZIP 95691-1025 city Do Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Street Number Received By: l.1 Street Name CITY STATE zip PHONE #1 EXT• ( ) APN # LAND USE APPLICATION # PHONE #Z EXT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: Veronica Freitas CHECK if BILLING ADDRESS® BUSINESS NAME SAN JOAQUN couNTy E,R O NMEW,j, PHONE # EXT. Walton Engineering, Inc. 916 373-1167 HOME or MAILING ADDRESS FAX # DATE: P.O. Box 1025 (916)373-1172 PIE: 0368 CITY West Sacramento STATE CA ZIP 95691-1025 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 SIGNATURE: 1� J DATE: 6/27/2012 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Service Contractor IfAPPLICANT is not the BILGING 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: U S COMMENTS: R. ' JUN 2 8 2012 SAN JOAQUN couNTy E,R O NMEW,j, RrilENT ACCEPTED BY: EMPLOYEE M DATE: / ASSIGNED TO' EMPLOYEE M DATE: Date Service Completed (if already Completed): SERVICE CODE: PIE: 0368 Fee Amount: Amount Paid Payment Date Le(ZA Payment Type r Invoice # Check # L+ ) Z, 4 Received By: l.1 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003