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SAN JOAQUIN JOUNTY ENVIkOf iAENTAL HEALTHtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MD r;:'' \V/ EDD <br />U <br />FACILITY ID # <br />CHECK If BILLING ADDRESSBUSINESS <br />SERVICE REQUEST # <br />Retail Fuel <br />P <br />b-70 <br />HOME Or MAILING ADDRESS <br />P.O. Box 1025 <br />If�©OSS&© V -7 <br />OWNER / OPERATOR <br />373-1173 <br />CITY West Sacramento <br />Quik Stop Market, Inc. <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />QuiJtC{ Stop #148 <br />Cr) f_,l Vtl=t <br />SITE ADDRESS 205 <br />W <br />Lockeford Street <br />ASSIGNED TO: <br />Lodi <br />I <br />95240 <br />Street Number <br />DirectionStreet <br />Name— <br />Date Service Completed (if already Completed): <br />ci <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount:134- <br />S oa <br />Amount Paid 3 4 S u <br />Street NumStreet <br />Payment Date g (� q <br />Name <br />CITY <br />Invoice # <br />STATE ZIP <br />PHONE #1 EXT. <br />b 4r=_�' S°o <br />APN # <br />LAND USE APPLICATION # <br />( 519 657-8500 <br />f�'fr _ ((or—IS. <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />2— <br />CONTRACTOR <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Webb <br />MD r;:'' \V/ EDD <br />U <br />CHECK If BILLING ADDRESSBUSINESS <br />NAME Walton Engineering, <br />Inc. <br />2009 <br />P <br />373-1166 EXT. <br />HOME Or MAILING ADDRESS <br />P.O. Box 1025 <br />ENVIRONMENT HEALTH <br />FAX <br />373-1173 <br />CITY West Sacramento <br />STATE <br />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 14EALTH 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: Q� DATE: - f C' -y-J <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTU Compliance Manager <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tette <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: C,c-S 7- <br />4�C 7-P— ,oF I <br />COMMENTS: <br />SA ENoi\ou"' <br />HEALTH DEPwRTie�E <br />ACCEPTED BY: <br />Cr) f_,l Vtl=t <br />EMPLOYEE <br />0-324 <br />DATE: ��09 <br />ASSIGNED TO: <br />0- A G•4 T- <br />EMPLOYEE #: <br />f LfZ Z <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: g <br />P I E: 3 <br />Fee Amount:134- <br />S oa <br />Amount Paid 3 4 S u <br />Payment Date g (� q <br />Payment Type <br />t S <br />Invoice # <br />Check # Lf <br />b 4r=_�' S°o <br />Received By: <br />EHD 48-02-025 f SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />