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SAN JOAQUIO-OUNTY ENVIRONMENTAL HEALTHTEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# GAS STATION,, SALE OF FOOD ITEMS &REVERAnE.S. AND CAR WASH OWNER/OPERATOR MIKE GATES c/o RALEY'S CHECK If BILLING ADDRESS❑ FACILITY NAME RALEY'S FUEL STATION #356 SITE ADDRESS 4255 E. MORADA LANE STOCKTON 95212 Direction Street Number DireStreet Nem. city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 500 WEST CAPITOLVE1UE Street Number reef ame CITY STATE ZIP WEST SACRAMENTO CA 95605 PHONE#I Err' APN# LAND USE APPLICATION# ( 916) 373-3333 124-290-08 USE PERMIT #123-03 PHONE#Y Exc BOIS DISTRICT LOCATION CODE O. ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR JEFFREY LEE c/o eda - design professionals CHECK If BILLING ADORES BUSINESS NAME PHONE# Exr. eda - design professionals 605 546-2050 HOME Or MAILING ADDRESS FAX# 1998 SANTA BARBARA STREET SUITE 200 605 )546-2053 CI9AN LUIS OBISPO CA STATE 93401 ZIP BILLING ACKNOWLEDGEMENT: 1, 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: PROPERTY ❑ L'1 PROPERTY/BUSINESS OWNEROPERATOR/ OTHER AUTHORIZED AGENT PROJECT MANAGER IfAPPLLCANT is not the BILLING PAR Tr proof of authorization to sign is required Tette 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 to me or my representative. TYPE OF SERVICE REQUESTED: �y /� COMMENTS: /1/�CL h short- IDtI,GQ �I.( ra'(,.�� — (O ,rJC I1L1c.l�r Cf� pp�j�{IVII' VGt��C.� c fo SK_, L./52 RIE-CEIVED OCT 1 12005 ACCEPTED BY: EMPLOYEE M �� ffLIT9R i- ASSIGNEDTO: EMPLOYEE#: DATE:ffP1 Date Service Completed (if already completed): SERVICE CODE: L / p Fee Amount: D Amount Paid ;;L 5;D Payment Date Payment Type Invoice# Check# L�8 y Z Received By: I�\,G EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003