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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST51 )o t�7 (G�� <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station fA c07D' <br /> OWNER / OPERATOR <br /> Charter Way Holdings , LLC CHECKifBILLING ESSE] <br /> FACILITY NAME 1720 South Fresno Ave . <br /> SITE ADDRESS 1720 S Fresno Ave . Stockton 95206 <br /> Street Number Direction 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 #'I EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT . <br /> Walton Engineering , Inc e16 73-1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ( ) <br /> CITY STATE CA ZIP 95691 <br /> West Sacramento <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 : �l OWI Aaazt� DATE : 2/ 1 /24 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I 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 provided to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : ,{ <br /> COMMENTS : <br /> ACCEPTED BY : B 1� EMPLOYEE # : DATE: �j <br /> ASSIGNED TO : EMPLOYEE # : DATE :CO <br /> Date Service COmple ( if already complete ci 2 SERVICE CODE : (� �1 Q P I E : r2 3 <br /> L <br /> ount: j� Amoulnt Paid Payment Dateunt Type I``nvoice # Check # Received By : <br /> EHD 48-02-025 X11 f /� SR FORM (Golden Rod) <br /> 07/17/08 / <br />