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ti <br />SAN JOAQ* COUNTY ENVIRONMENTAL HEAL*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />6`11 <br />SERVICE REQUEST # <br />t a,06 40-1 / 1;_3 <br />OWNER / OPERATOR <br />Quik Stop Market, Inc. <br />CHECK If BILLING ADDRESSO <br />FACILITY NAME <br />Quik Stop #152 <br />373-1166 ExT. <br />SITE ADDRESS 1721 <br />Street Number <br />S <br />I Direction <br />Cherokee Lane #1 -T <br />Street Name <br />Lodi <br />city <br />95240 <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 Exr. <br />( 519 657-8500 <br />APN # <br />LAND USE APPLICATION # <br />PHONE R Err. <br />HEALTH DEPARTMENT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />/,��/ i <br />CHECK If BILLING ADDRES <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: 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: L� 4^---- DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT U Compliance Manager <br />IfAPPLICANT is not the BiLLiNGPARnI 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: �C�T <br />/,��/ i <br />PAYMENT <br />PECEIVED <br />COMMENTS: <br />MAR 2 5 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />&VZAJ6 <br />EMPLOYEE M ?0,V -T <br />DATE: <br />ASSIGNED TO: <br />-4 / T <br />4-C-44 <br />EMPLOYEE M ZZ <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />b <br />P 1 E: a 3 b <br />Fee Amount: <br />3 �(� O <br />Amount Paid -6 3 (o (o . <br />Payment Date 3 yS- <br />Payment Type <br />✓ <br />Invoice # <br />Check # Lf 3q3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />