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SAN JOAQ40 COUNTY ENVIRONMENTAL HEALIO)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> retail gas station <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc . CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Quik Stop #152 <br /> SITE ADDRESS S Cherokee Ln. Lodi 7Zip <br /> 5240 <br /> 1721 Street Number Direction Street Name Ci Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT j LOCATIO CDD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. (916 ) 373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916 )373-1173 <br /> CITY West Sacramento STATE CA 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:1". r-7�Q�' DATE: 9/4/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® contractor <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: s P/aYM <br /> COMMENTS: EQ <br /> SEP 0 5 2012 <br /> SAtv HSN Rp pMEI OUU.NTy <br /> ��ENT <br /> ACCEPTED BY: KV\�� �, i Zr" EMPLOYEE#: DATE: I 'Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: ll I Z <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: .Z 30�7 <br /> Fee Amount: --7 Amount Paid �j�JC Payment Date q15112 <br /> Payment Type ✓ Invoice# Check# ass S Received By: N <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />