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SAN JOAQbPCOUNTY ENVIRONMENTAL HEALTH RPARTMENT <br />SERVICE REQUEST <br />Type of Business :Property <br />FACILITY ID # <br />Freitas <br />SERVICE REQUEST # <br />Gas Station <br />RECEIVED <br />Poo 6 _ <br />OWNER / OPERATOR <br />1 373-1167 <br />Tower Ener Group <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />P.O. BOX 1025 <br />Tower Mart # 104 <br />( ) 373-11 3 <br />SITE ADDRESS 192 <br />I <br />Lathrop <br />_ <br />ASSIGNED TO: <br />Lathrop <br />95330 <br />Street Number <br />Direction <br />Street Name <br />SERVICE CODE: ) c7Q <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />3 7S (� <br />Payment Dateuu <br />Street Number <br />Payment Type <br />Street Name <br />CITY <br />Check # 1 7 <br />Received By. <br />STATE ZIP <br />PHONE #t En. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REOUESTOR <br />REQUESTOR <br />Veronica <br />Freitas <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME Walton Engineering, Inc. <br />RECEIVED <br />PHONE# En. <br />JAN 3 0 2014 <br />1 373-1167 <br />HOME Or MAILING ADDRESS <br />SAN JOAouw COU <br />FAx# <br />P.O. BOX 1025 <br />HEALWROHMEKTq� <br />TH OEPARTMENr <br />( ) 373-11 3 <br />CITY West Sacramento <br />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: Q �' IvL N rVj/ .,ifs fidr- - DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/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 t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: u 5 r - <br />f AY <br />COMMENTS: <br />RECEIVED <br />JAN 3 0 2014 <br />SAN JOAouw COU <br />HEALWROHMEKTq� <br />TH OEPARTMENr <br />ACCEPTED BY:IA n /n //1 y` <br />VVI �1�1 <br />EMPLOYEE #: / O <br />DATE: j / <br />_ <br />ASSIGNED TO: <br />EMPLOYEE#: 7L (, / <br />DATE: <br />Date Service Completed (If already Completed): <br />SERVICE CODE: ) c7Q <br />P I E: -22 g <br />Fee Amount• 3 7 -�_ <br />Amount Paid <br />3 7S (� <br />Payment Dateuu <br />Payment Type <br />Invoice # <br />Check # 1 7 <br />Received By. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />