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. + as <br />SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTIO-PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FA ILITY ID # <br />�(j <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Quik Stop Market, Inc. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Quik Stop #148 <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />SITE ADDRESS 2 05 <br />Street Number <br />W <br />Direction <br />Lockeford Street <br />Street Name <br />7Lodi <br />city <br />T95240 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CIN <br />STATE ZIP <br />PHONE #1 EXT• <br />( 519 657-8500 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR , <br />REQUESTOR Dulcinea Covan <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />P <br />373-1166 Ext. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />FAX# <br />016) <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />ZIP 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, Standa and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C$ 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: a-S'r � T <br />COMMENTS: <br />PAY VII!NT <br />RECEIVED <br />AUC 1 1 2011 <br />SAN JOAQUIN COUNT`( <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />LC uJ67 <br />EMPLOYEE #: ! <br />DATE: 314 (at / <br />d� <br />ASSIGNED TO:- <br />t <br />EMPLOYEE #: r ZZ <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P I E: <br />Fee Amount: <br />1� <br />Amount Paid <br />Payment Date ! l <br />Payment Type <br />✓ <br />Invoice # <br />Check # <br />Re eived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />