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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station tnL' / <br /> OWNER / OPERATOR <br /> Speedway CHECK If BILLING ADDRESS <br /> FACILITY NAME Speedway # 4492 <br /> SITE ADDRESS 2132 Mariposa Road Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 539 South Main Street <br /> Street Number Street Name <br /> CITY Findlay STATE ZIPOH 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 <br /> Kristin Nappen CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # ExT. <br /> Walton Engineering , Inc. 916 373- 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> P . O . Box 1025 ( 916) 373- 1172 <br /> CITY STATE ZIP <br /> West Sacramento CA 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, S ATE @nd FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE , 7- 15- 19 <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS pr i' ded to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : C ( ' J I �' f-12 l <br /> COMMENTS: Al <br /> Jt <br /> ` � ? ?019 <br /> N4 1 'yO/v COlv U, <br /> FP,gRTM NT <br /> ACCEPTED BY: �� �' ?7 EMPLOYEE #: �/ DATE: <br /> ASSIGNED TO : ��/ / r�/ G ( EMPLOYEE # : [ � j DATE: <br /> Date Service Completed ( if already completed) : SERVICE/CODE : le7f P / E: � r}�' <br /> Fee Amount: �(� " Amount Paid � , (�� Payment Date <br /> Payment Type Invoice # Check # �3 Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />