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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property //FACILITY ID # SoUX <br /> SERVICE REQUEST # <br /> Gas Station �J 7 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Speedway, LLC <br /> FACILITY NAME Speedway #4681 <br /> SITE ADDRESS 2500 W Lodi Avenue Lodi 95242 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 539 South Main Street Street Number Street Name <br /> CITY STATE ZIP <br /> Findley OH 45480 <br /> PHONE #1 ExT APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kristin Nappen CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT• <br /> Walton Engineering, Inc. <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ( ) <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 ap lic ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TE and F RAL laws . <br /> APPLICANT' S SIGNATUR DATE ; <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT gContractor <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 anle same time it is <br /> provided to me or my representative . toWN <br /> TYPE OF SERVICE REQUESTED : �� <br /> COMMENTS : �iQr ,✓O ?� <br /> ti �;'Poi 1�J9 <br /> �A' 01z <br /> NT <br /> ACCEPTED BY : Q jr�� EMPLOYEE #: DATE * <br /> ASSIGNED TO : Po, A4rt G EMPLOYEE M M43�0 DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : 1 / 3 PIEa OL <br /> : r� <br /> Fee Amount: vJ'� `'v Amount Paid P <br /> Payment Date SZ3 <br /> Payment Type Invoice # Check # 33 � Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />