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SAN JOAQUIPPUNTY ENVIRONMENTAL HEALTPARTMENT <br /> SERVICE REQUEST !� <br /> Type of Business or Property FACILITY IDS#; SERVICE REQUEST# <br /> Gas Station � i 13L c6-7 ' 0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Quik Stop , Inc. ❑ <br /> FACILITY NAME <br /> Quik Stop #152 <br /> SITE ADDRESS 1721 S Cherokee Lane#1 Lodi 95240 <br /> Street Number I Directio tr et Name City Zipode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY Fremont STATE CA Zip 94538 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#T EXT BOS DISTRICT ( LOCATION CODE <br /> ( ) ©� �1 C1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916 373-1166 <br /> HOME or MAILING ADDRESS Fax# <br /> P.O. Box 1025 ( ) 373-1171 <br /> CITY West Sacramento STATE CA Zip <br /> 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 wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FERE ws. <br /> APPLICANT'S SIGNATURE: DATE: 7/27/18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> IfAPPL/CANT 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: — PAYMENT <br /> LIJ <br /> COMMENTS: <br /> Cho tb 14a- JUL 3 0 20� <br /> SAN JOAQUIN COUNT <br /> ENVIMMMENM <br /> HEIII.TH <br /> ACCEPTED BY: EMPLOYEE#: DATE: '-;x <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P I E: 2 3, <br /> Fee Amount: a� Amount Paid Cj I a Payment Date ? 3 O t' <br /> Payment Type C`L— Invoice# Check# 53 q 6 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />