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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Q`�� V� C FACILITY ID # SERVICE REQUEST # Ground -Up New Gas Dispensing Facility Walton Engineering, Inc. S R Q)0 g �7 8 7 OWNER / OPERATOR 3788Tracy, LLC FAX # CHECK if BILLING ADDRESS FACILITY DAME ( 916 ) 373-1172 CITY West Sacramento STATE CA ZIP 95691 Triangle Plaza Tracy SITE ADDRESS "11, n /yao /iY /��il`.L/ EMPLOYEE #: DATE: z —7 Z 3788 Tracy Blvd. I Date Service Tracy SERVICE 95304 iWWWWStreet Number Direction 2 U Amount Paid Street Name City Payment Type Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # Receiv d By: 2620 Old First Street Street Number Street Name CITY STATE ZIP Livermore CA 94550 PHONE #1 EXT, qPN # LAND USE APPLICATION # (408 )638-1339 PHONE #2 ( ) EXT. WWWW BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REOUESTOR REQUESTOR BILLING ACKNOWLEDGEMENT: I, the undersigned propert Q`�� V� C Sarah Jablonsky -Construction Manager CHECK if BILLING ADDRESS BUSINESS NAME PHONE # Exr. Walton Engineering, Inc. 916 373-1165 HOME or MAILING ADDRESS FAX # PO Box 1025 ACCEPTED BY: ( 916 ) 373-1172 CITY West Sacramento STATE CA ZIP 95691 y or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be perf ormed will be done in accordance with all SAN JOAQUIN OOUNTY Ordinance Codes, Standards, STATE and FEDERAL IaWS. APPLICANT'S SIGNATURE: y DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ®Construction Manager If APPLICANT IS not fhe BILLING PARTY. proof Of aufhorizafion t0 Slg/1 IS required Tirle AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is proved to me or my representative. A,d VJI AN WWI Azi 71/1 TYPE OF SERVICE REQUESTED: 17E 7g(! 35 Q`�� V� C COMMENTS: AR ?9 sqN ?0? M COU AL ry t AME N C ARTME ACCEPTED BY: I c Il\ i /1 li l L EMPLOYEE #: DATE: �� ASSIGNED TO: "11, n /yao /iY /��il`.L/ EMPLOYEE #: DATE: z —7 Z Date Service Completed (if already Completed): SERVICE CODE: _ ' P / E: 23 O J Fee Amount: 2 U Amount Paid 3 Z� DD i Payment Date Payment Type C'R�i i- Invoice # Check # Receiv d By: EHD 48-02-025 07/17/08 � SR FORM (Golden Rod) Ty r