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SAN JOAQIWOUNTY ENVIRONMENTAL HEALAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />0 <br />SERVICE REQUEST # <br />gas station <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />OWNER / OPERATOR <br />ExT' <br />CHECK if BILLING ADDRESS <br />Quik Stop Markets, Inc. <br />(916)373-1167 <br />FACILITY NAME <br />FAX # <br />Quik Stop Market #148 <br />P.O. Box 1025 <br />3%�J <br />SITE ADDRESS <br />W <br />I <br />Lockeford Street <br />STATE <br />Lodi <br />95240 <br />205 Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(209)369-1142 <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />0 <br />Veronica Freitas <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE M <br />PHONE # <br />ExT' <br />Walton Engineering, Inc. <br />DATE: <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />FAX # <br />Fee Amount: .1 ", <br />P.O. Box 1025 <br />3%�J <br />( ) <br />CITY <br />STATE <br />ZIP <br />West Sacramento <br />CA <br />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: iy�i�„ �}�� DATE: A/141 /19 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® contractor <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:RECEIVED <br />SEP 0 4 2012 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: D <br />Fee Amount: .1 ", <br />Amount Paid <br />3%�J <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # gs5q g <br />Received By: NJ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />