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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT If <br />EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME Walton Engineering, Inc. <br />SERVICE REQUEST # <br />Retail Fuel <br />EXT. <br />C� <br />(916)373-1166 <br />OWNER/ OPERATOR <br />HOME or MAILING ADDRESS <br />7 -Eleven ITIC. <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME 7 -Eleven #2369-19976 <br />SITE ADDRESS 1199 <br />N <br />I <br />Main Street <br />I <br />ZIP 95691 <br />Manteca <br />95337 <br />Street Number <br />Direction <br />Street Name <br />city <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Webb <br />CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME Walton Engineering, Inc. <br />PHONE# <br />EXT. <br />(916)373-1166 <br />HOME or MAILING ADDRESS <br />FAX # <br />P.O. Box 1025 <br />(916)-373-1173 <br />CITY West Sacramento <br />STATE CA <br />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 <br />or activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ,jam_ -f2 DATE: �l U <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Manager <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: F (� pAYM E <br />COMMENTS: / 1 <br />Nov <br />vr 3 '��9 <br />1 �IVV <br />SAN JOAOUI r-rl(rf7i <br />HEEALTH NVIRONM DEPART �ry16RV/ <br />C, <br />ACCEPTED BY: t— t V` t p2, EMPLOYEE M 0 32—i DATE: r� 131 <br />0 <br />ASSIGNED TO: EMPLOYEE M 2--Q-70 DATE: It 0 10 <br />Date Service Completed (if already completed): SERVICE CODE: P I E: z3�� <br />Fee Amount: 3 4,S- Amount Paid X345 0 0 Payment Date <br />Payment Type L�' Invoice # Check # Lf 'xp Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />