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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property RF _ FACILITY ID # BUSINESS NAME Walton Engineering, Inc. SERVICE REQUEST # Retail Gas Dispensing Facility Exr' 373-1165 HOME Or MAILING ADDRESS PO Box 1025 EMPLOYEE #: Fax# (916-) OWNER/OPERATOR CITY West Sacramento CHECK N BILLING ADDRESS Colonial Energy, LLC. Fee Amount: Amount Pale390.ODPayment FACILITY NAME Colonial Energy #40135 /l / 3 l3 Payment Type SITEADDRESS 192 Check # 5 -OZ Lathrop Road Lathrop 95330 Street Number Direction Stree[Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2860 N. Santlag Blvd. 2nd Floor Street Number 5 met Name CITY Orange STATE CA ZIP 92867 PHONE #1 En. APN # (9to LAND USE APPLICATION # (714 ) 761-5426 PHONE #2 Ear. ( ) BOS DISTRICT LOCATION CODE /, CONTRACTOR / SERVICE REQUESTOR REQUESTOR Walton Engineering, Inc. (Angel Rodriguez) RF _ CHECK if BILLING ADDRESS® BUSINESS NAME Walton Engineering, Inc. ACCEPTED BY: PHONE # 916 Exr' 373-1165 HOME Or MAILING ADDRESS PO Box 1025 EMPLOYEE #: Fax# (916-) 373-1172 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property 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. I 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: DATE: 11-11-15 PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER❑ OTHER AUTHORIZED AGENT Ma Project Manager IfAPPL/CANT 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is nrovided to me or my representative. TYPE OF SERVICE REQUESTED: Cold Start for POS Upgrade RF _ COMMENTS: NO Kea 6,4 N�,p�t/'pCfo0 i7 e�q 4t'rr ACCEPTED BY: EMPLOYEE#: DATE: /t>-/� ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if alread ompleted): SERVICE CODE: P I E: a �� Fee Amount: Amount Pale390.ODPayment Date /l / 3 l3 Payment Type Invoice # Check # 5 -OZ Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003