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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 rAo v y t Y S F( 00 8 7 4 (Q (p <br /> OWNER / OPERATOR <br /> Speedway LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Speedway #6187 <br /> SITE ADDRESS 95204 <br /> 2705 Country Club Blvd . Stockton <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 /> ( ) Ia1 - al0 - 08 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsk - Construction Manager <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Walton Engineering , Inc . 16 373 - 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> PO Box 1025 ( 916 ) 373 - 1172 <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 : �a4414# 4 DATE : 11 /20/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR AMANAGER 6 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 . OVA <br /> /C <br /> TYPE OF SERVICE REQUESTED : / 747V <br /> COMMENTS : r7 VA' �— sN NAV ? 8 <br /> SA 4?3 <br /> Oq <br /> NE � D�pANE �NTfRT <br /> ENT <br /> ACCEPTED BY : \ `� EMPLOYEE # : DATE : 1112.01 <br /> l <br /> ASSIGNED TO : ; } j �i ( , �v EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : -- SERVICE CODE : ��(� (� PIE : 2 � <br /> Fee Amount : Amount Paid dv Payment Date 1112L417y 10 V I <br /> 23 <br /> Payment Type ` Invoice # Check # � 56 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />