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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ii11��,,'' FACILITY ID # SERVICE REQUEST # Stephanie Charissa Facility BUSINESS NAME DATE: PHONE# ExT. Ground -Up New Gas Dispensing 1 916 343-3857 HOME or MAILING ADDRESS Payment Date FAX# PO Box 1025 Check # ( ) CITY West Sacramento OWNER / OPERATOR 3788Tracy, LLC CHECK If BILLING ADDRESS FACILITY NAME Triangle Plaza Tracy SITE ADDRESS 3788 Tracy Blvd, I Tracy 95304 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2620 Old First Street Street Number street Name CITY STATE ZIP Livermore CA 94550 PHONE #1 ExT. APN # LAND USE APPLICATION # (408 )638-1339 PHONE #2 ( ) EXT, BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR BILLING ACKNOWLEDGEMENT: I, the undersigned property ii11��,,'' ACCEPTED BY: CHECK If BILLING ADDRESS�G.1 Stephanie Charissa ASSIGNED TO: BUSINESS NAME DATE: PHONE# ExT. Walton Engineering, Inc. P I E: 1 916 343-3857 HOME or MAILING ADDRESS Payment Date FAX# PO Box 1025 Check # ( ) CITY West Sacramento STATE CA ZIP 95691 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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ShDl�lCA" fi�'rRi DATE: 08/09/202 4 PROPERTY /BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ®Operations Coordinator If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title 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 provided t0 me Or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08