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SAN JOAQUINOUNTY ENV RONMENTAL HEALTI&PARTMENT <br /> r , <br /> _ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> Retail Fuel <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> Quik Stop Market, Inc . <br /> FACILITY NAI19E <br /> QuitK{ Stop #148 <br /> SITE ADDRESS 205 W Lockeford Street Lodi 95240 <br /> Street Number I Direction Street Name city ZI12 Code <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#1 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dul c inea Webb CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc. P373-1166 ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 1025 (916 ) 373-1173 <br /> CITY West Sacramento STATE CA 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 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: �1 _ DATE:� "lI' (D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTL`r 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, 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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> ccvic�n 11/17/9nnl <br />