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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIOPARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel FACILITY ID # S CHECK If BILLING ADDRESS Et SERVICE REQUEST # OWNER/ OPERATOR Quik Stop Market, Inc. P CHECK if BILLING ADDRESS❑ FACILITY NAME Quik Stop #152 FAX# 016) SITE ADDRESS 1721 Street Number SCherokee DirectionStreet Lane #1 Name ZIP 95691 Lodi city 95240 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number ACCEPTED BY' Street Name CITY EMPLOYEE #: STATE ZIP PHONE #1 EXT. ( 519 657-8500 APN # LAND USE APPLICATION # PHONE #2 EXT. Date Service Completed (if already completed): BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan f S I CHECK If BILLING ADDRESS Et BUSINESS NAME Walton Engineering, Inc. COMMENTS: P 373-1166 E>R. HOME or MAILING ADDRESS P.O. Box 1025 FAX# 016) 373-1173 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Stand STATE and FEDERAL laws. APPLICANT'S SIGNATURE: It [3L DATrE� PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ? Compliance Manager If APPLICANT is not the B1LLiNG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. —r -r, TYPE OF SERVICE REQUESTED: f S I VAI CENED - COMMENTS: JUL 19 2011 �i JOAQUfN COUNTY ENVIRONMENTAL DEPARTMErr HEALTH ACCEPTED BY' EMPLOYEE #: DATE: / 1 ASSIGNED TO: t EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: pr Fee Amount: Cyb Amount Paid 3 D D Payment Date ,q Payment Type ✓ Invoice # Check # 4 Z� S" Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003