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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility C%�)CC>c SIC 0ot4S�4J <br /> OWNER / OPERATOR <br /> Speedway LLC CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> Speedway #1486 <br /> SITE ADDRESS E . Hwy 88 Lockeford 95237 <br /> 13975 <br /> Street Number Direction I 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 /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <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 /> PO 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 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 : DATE : 09/02/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO MANAGER b OTHER AUTHORIZED AGENT 0 Construction Manager <br /> If APPLICANT is not the BILLING PARTY, /hoof 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 /> 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 . <br /> TYPE OF SERVICE REQUESTED : Us 7T P�4tn it Pq <br /> COMMENTS : CEFi E <br /> SEP <br /> 0920241 <br /> SA N JOA <br /> NVIRO UIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : , ( Z a C 1 EMPLOYEE #: DATE: <br /> ASSIGNED TO : / n N , L EMPLOYEE #: DATE : <br /> Date Service Completed ( if already Completed ) : SERVICE CODE : JeU 2 ? rl P I E : .9 <br /> Fee Amount: & 4 Amount Paid Payment Date L2 <br /> Payment Type Ck { qGbP} Invoice # Check # 0 Received By : <br /> Z - <br /> EHD 48-02-025 / / SR FORM (Golden Rod ) <br /> 07/17/08 <br />