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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # c nSERVICE REQUEST # <br /> Gasoline Dispensing Facility 6OD20 SO 001ZL4 SO <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Speedway <br /> FACILITY NAME Speedway #6187 <br /> SITE ADDRESS <br /> 2705 Country Club Blvd . Stockton 95204 <br /> Street Number Direction Street Name city Zip 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 /> (209 ) 939-9295 1 1 0Z Z I C)0 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) !LJ~l1J (D I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Sarah Jablonsky - Construction Manager <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc. 916 373- 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> �P�TOY Box 1025 ( 916 ) 373- 1172 <br /> 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : Wool DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Construction Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sigh IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It Is provided t0 me or <br /> my representative . JbA <br /> TYPE OF SERVICE REQUESTED : S R FNT <br /> (0,4 <br /> COMMENTS : D <br /> AUG 12 20 <br /> �SSANLjOAQ20 <br /> ATHEIgpP <br /> RTM T Y� <br /> ACCEPTED BY : Q EMPLOYEE # : DATE: Z7� <br /> ASSIGNED T EMPLOYEE #: DATE: <br /> Date Service Complet 44f already completed) : — SERVICE CODE : q tf PIE : . <br /> Fee Amount: 5WZ, &0 Amount Pai , U Payment Date 71 S <br /> Payment Type Invoice # Check # � S R ceiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />