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9163731173 WALTONENGINEERING PAGE 09/09 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH•PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID If <br />SERVICE REQUEST # <br />Gas Station <br />BUSINESS NAME Walton Engineering, Inc. <br />OWNER / OPERATOR <br />— <br />,rower Energy Group <br />CHECK If EIILLINO ADDRESSCI <br />FACILITY NAME <br />DATE: <br />Tower Mart#104 <br />Cm West Sacramento <br />SITE ADDRESS 192 Lathro P <br />Lathrop 95330 <br />01 Number <br />Amount Paid <br />HDME or MAILING ADDRESS Of Different from Site Address) <br />Payment Date <br />CITY <br />s umber Strobi Name <br />Check # <br />STATE MP <br />PHQNE41 Err. APN # <br />LAND USE APPLICATION ,# <br />f ) <br />PHONE 92 Err. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE I2E0TTV.Wn12 <br />REQDE$TOR <br />Veronica Freitas <br />CHECIYN SILLINMADARE51 <br />BUSINESS NAME Walton Engineering, Inc. <br />PHONE Err" <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />FAX #P.O. <br />Box 1025 <br />DATE: <br />( ) Z7�-1 173 <br />Cm West Sacramento <br />STATE CA zIP 95691 <br />-RiLLING At Icf4tawl EOGEMENT: 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 />I also cartify 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: JU/W^ S DATE: 01/28/14 <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M_ ContractnE <br />If APPLICAM' is not the BILUNG PARTY, proof ofauthoriration to sign is required Titre <br />AUTHORIZATION TO RE BAS INFORMATION: When applicable, 1, 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 envlronmental/site assessment information <br />to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as R Is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />CONMENIS: <br />ACCEPTED"BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />DateSerVloeCompleted of already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD <br />07/17/09 2.025 SR FORM (Golden Rod) <br />Received Time Feb, 1. 2014 9:50AM No, 5150 <br />