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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Sarah Jablonsky -Construction Manager SERVICE REQUEST # Gasoline Dispensing Facility PHONE # ExT. Walton Engineering OWNER/ OPERATOR ( 916) 373-1165 ❑ Schack & Company, Inc. FAX# CHECK if BILLING ADDRESS FACILITY NAME ( 916 ) 372-1888 CITY West Sacramento Edgewater Commercial Center NT SITE ADDRESS EMPLOYEE #: DATE: /� 2 4600 Street Number Direction S. Corral Hallovx Rd. Street Name EMPLOYEE #: Tracy ci 9P377 Code HOME or MAILING ADDRESS (If Different from Site Address) SERVICE CODE:05/ Street Number Fee Amount: a0 `i Q o0 Street Name CITY STATE ZIP PHONE #1 EXT• APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Sarah Jablonsky -Construction Manager CHECK if BILLING ADDRESS BUSINESS NAME PHONE # ExT. Walton Engineering ( 916) 373-1165 HOME or MAILING ADDRESS SAN `IOAQUI FAX# PO Box 1025 ( 916 ) 372-1888 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: VNI'la'A"I DATE: 3/4/21 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ THER AUTHORIZED AGENT W Construction Manager If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time !-47/v ed to me or my representative. ® F TYPE OF SERVICE REQUESTED: COMMENTS: AIA R 6 2021 SAN `IOAQUI NEgLTy p AR�NTy NT ACCEPTED BY: EMPLOYEE #: DATE: /� 2 ASSIGNED TO:O Yjf% f L EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE:05/ PIE: Fee Amount: a0 `i Q o0 Amount Paid513 OD Payment Date Payment Type( Invoice # Check # 5-7,; eceived By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08