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SAN JOAQUIbLCOUNTY ENVIfRONMENTAL HEALTILDEPARTMENT <br /> r <br /> SERVVEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel C0-5-ksloo <br /> OWNER/OPERATOR <br /> Quik Stop Market, Inc. CHECK if BILLING ADDRESSO <br /> FACILITY DAME Stop #148 <br /> SITE ADDRESS 205 WLockeford Street Lodi 95240 <br /> Street Number I ..Mdon I ftm blame cily ZIR C299 <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 519 657-8500 <br /> PHONE#2 EXT. BOS DISTRICT ill LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc. P 3 73-1166 ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 016 ) 373-1173 <br /> CITY West Sacramento STATE _ CA BP 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: cX-0- 05 <br /> PROPERTY/BUSINESS OWNER13 OPERATOR/MANAGER O OTHER AuTnoRiZED AGENT U Compliance Manager <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 t* e it is <br /> provided to me or my representative. I\A FNT <br /> TYPE OF SERVICE REQUESTED: 9;;� FEIN F1 REGt--1\f <br /> COMMENTS: <br /> N JOP'001N cout4v <br /> SEPI 4 20ff <br /> BEALTV,6ioxvll <br /> ENVIRONM NT HEA <br /> ACCEPTED BY: o L I <br /> —t EMPLOYEE#: 0-3 DATE: ?/F 0 <br /> ASSIGNED TO: CA CIA-?t-r-- EMPLOYEE#: J 2 DATE: <br /> Date Service Completed (if already completed): =SERVICE CODE: pit: <br /> Fee Amount: jLA-) ----TAmount Paid84 Payment Date <br /> Payment Type E Check Invoice# # Received By: <br /> 1A <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />