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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTOEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Retail Fuel JUL 15 2o'4' SAN JOAQUIN COUNTY ENVIRNETAL- HEAL-TH DEPpAR7MENT P§PTIV `Z12,06) &oybc) OWNER/ OPERATOR FAX # 016) Quik Stop Market, Inc. CITY West Sacramento CHECK If BILLING ADDRESS❑ FACILITY NAME Quik Stop #152 DATE: / Date Service Completed (if already completed): SITE ADDRESS 1721 S Cherokee Lane #1 Fee Amount: 0 3,qr� � Lodi T95240 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT• APN # LAND USE APPLICATION # ( 519 657-8500 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan DECEIVE® CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. JUL 15 2o'4' SAN JOAQUIN COUNTY ENVIRNETAL- HEAL-TH DEPpAR7MENT P§PTIV 373-1166 EXT. 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 7�'C---L- DATE: � ROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER 13L7 OTHER AUTHORIZED AGENT Compliance Manager If APPLICANT is not the BILLING 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. ■ c n l r TYPE OF SERVICE REQUESTED: �l j �ET��/% DECEIVE® COMMENTS: JUL 15 2o'4' SAN JOAQUIN COUNTY ENVIRNETAL- HEAL-TH DEPpAR7MENT ACCEPTED BY: Ell EMPLOYEE #:� DATE: ASSIGNED TO: V 5 6��` EMPLOYEE #: / DATE: / Date Service Completed (if already completed): SERVICE CODE: J �� P / E: Fee Amount: 0 3,qr� � Amount Paid 3Y6 4& Payment Date t7 0 Payment Type ✓ Invoice # Check # 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003