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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 FACD003f0052. F**�ft 0 Z W7 01 d- 3 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Speedway LLC <br /> FACILITY NAME <br /> Speedway #4873 <br /> SITE ADDRESS North Cherokee Lane Lodi 95240 <br /> 35 Street Number Direction Street Name Cit Zi 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 /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc . 91 373 - 1165 <br /> HOME or MAILING ADDRESS PO Box 1025 FAx # <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/ 19/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Construction Manager <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 provided to me or <br /> my representative . PA VA <br /> TYPE OF SERVICE REQUESTED : EC <br /> COMMENTS : D <br /> SEP 26 ?0? <br /> SAN `IOAQUI <br /> NEgLTH pPR ` TY <br /> E T <br /> ACCEPTED BY : 1V /J �/� _ EMPLOYEE # : DATE : g � � <br /> ASSIGNED TO : vtaVW�3 _ L, e e v� EMPLOYEE #: Ci fi " DATE: 7l <br /> Date Service Completed ( if already completed ) : SERVICE CODE : ri w2v PIE :: �✓ <br /> Fee Amount : Ozl f& AmountPaf4T> L O� Payment Date Z3 <br /> Payment Type W Invoice # Check # ! (oq �� 2 Recei ed By : <br /> EHD 48-02-025 SR FORM ( Golden Rod) <br /> 07/ 17/08 <br />