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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Ground-Up New Gas Dispensing Facility S N g 7 8 79 <br /> OWNER/ OPERATOR <br /> 3788Tracy, LLC CHECK if BILLING ADDRESS <br /> FACILITY DAME <br /> Triangle Plaza Tracy <br /> SITE ADDRESS <br /> 3788 Tracy Blvd. Tracy 95304 <br /> Street Number Direction Street Name CityZiP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2620 Old First Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Livermore CA 94550 <br /> PHONE#1 EXT. qpN # LAND USE APPLICATION# <br /> (408 )638-1339 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916 373-1165 <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: SA,,d� � L DATE: <br /> PROPERTY/ BUSINESS OWNER ❑ OPERA OR/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 provjded to me or <br /> my representative. / A <br /> TYPE OF SERVICE REQUESTED: r <br /> COMMENTS: D <br /> qN MAR 29 <br /> s ?0? <br /> NFA TH O pM��q L TY <br /> ARTME T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 1 "1 1 n /1 /%a Ilrt EMPLOYEE #: DATE: z—7 z <br /> Date Service Completeed (if already completed): IL SERVICE CODE: _ �Gj�' P/E: Z3 0 3 <br /> Fee Amount: V J 2 '4 U Amount Paid ,3 Z DD Payment Date l zq <br /> Payment Type ���� Invoice # Check # Receiv d By: <br /> 17E79 (!� 351 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />