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SAN JOAQUIIAOUNTY ENVIRONMENTAL HEALTHWARMply <br />Q <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Quik Stop Market, Inc. <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Quik Stop #152 <br />373-1166 Exr. <br />SITE ADDRESS 1721 <br />Street Number <br />S <br />Direction <br />Cherokee Lane #1 <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 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 Dul c inea Covan <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />DATE: <br />P§0i <br />373-1166 Exr. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />Date Service Completed (if already completed): <br />FAX # <br />(916) <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:_ C-- --- DATE: " �%A -(O <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a Compliance Manager <br />IfAPPLICANT 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: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Tp/ E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />