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SAN JOAQUIN )UNTY ENVIRONMENTAL HEALTH D %RTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station Ea 6000 q J Il' -L Cj6i 7 n? k�b OWNER / OPERATOR Walton Engineering, Inc. CHECK if BILLING 7 -Eleven, Inc. HOME or MAILING ADDRESS ADDRESSO FACILITY NAME P.O. Box 1025 SERVICE CODE: t , 7 -Eleven #19976 CITY West Sacramento STATE CA zip 95620 SITE ADDRESS Payment Type ✓ 7 Invoice # Check # J 3 c�� Received By: LIWO 1399 N Main Street Manteca 95336 Street Number Direction Street Name Cit ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( ) \ dc PHONE #2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Veronica Freitas Z 6 s4v'04 ?Ole BUSINESS NAME PHONE # EXT. Walton Engineering, Inc. EMPLOYEE #: 916 373-1166 HOME or MAILING ADDRESS EMPLOYEE #: FAX # P.O. Box 1025 SERVICE CODE: t , (916)373-1173 CITY West Sacramento STATE CA zip 95620 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. 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: ceu� A-Zfa� DATE: h L PROPERTY / BUSINESS OWNER 1:1 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT l3 Contractor 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 to me Or my representative. TYPE OF SERVICE REQUESTED: R 1'tiJF COMMENTS: FQ SFp Z 6 s4v'04 ?Ole N��aFq �FHT,ti'�Y ACCEPTED BY: A EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: a 1 Date Service Completed (if already completed): SERVICE CODE: t , PIE: Fee Amount: L+ c,t✓ Amount Pai 4 Payment Date 9/ IG Payment Type ✓ 7 Invoice # Check # J 3 c�� Received By: LIWO EHD 48-02-025 SR FORM (Golden Rod) 07/17/08