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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station _ o 5 Roa400 a 3q <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Quik Stop Markets , Inc . � <br /> FACILITY NAME <br /> Quik Stop # 120 <br /> SITE ADDRESS9321 Thornton Rd . Stockton 95209 <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 #t EX APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Walton Engineering , Inc e16 373- 1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ( ) <br /> CITY STATE ZIP 95620 <br /> West Sacramento CA <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 : 05/21 /2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 13 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 . P <br /> TYPE of SERVICE REQUESTED : C� t _ r r L 1 r l C <br /> COMMENTS: C) L <br /> SAN JVZ <br /> J 12 2024 <br /> EN ROU/N COU <br /> NEAL7-H DEpAj TrAL <br /> ACCEPTED BY : f 1 v EMPLOYEE #: DATE: <br /> ASSIGNED TO : �� 1 EMPLOYEE # : DATE. <br /> Date Service Completed ( if already completed ) : — SERVICE CODE : 0 �2q PI E : '15 O S <br /> Fee Amount: �' L� %� Amount Paid �� . Payment Date I �p 2 <br /> Payment Type Invoice # Check # / g17 � (��(� b Received By : <br /> 1 $Z�ts¢- 1o2- <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />