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Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station OWNER / OPERATOR CHECK if BILLING ADDRESS FACILITY NAME 7 -Eleven #35355 SITE ADDRE- - SS 3202 West ammer Lane Stockton 95209 Street Number Direction HOME or MAILING ADDRESS (If Different from Site Address) Street Name Cit Zi Code Street Number Street Name CITY STATE Zip PHONE #1 Exr. ( ) APN # LAND USE APPLICATION # PHONE #2 Exr. BOS DISTRICT LOCATION CODE ...� ! ' ERVICE ! EQUESTON- k Veronica Freitas BUSINESS NAME Walton Engineering, Inc. HOME or MAILING ADDRESS P.O. Box 1025 CITY West Sacramento CHECK if BILLING ADDRESS PHONE # Exr. _(916)373-1167 FAx # 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. 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, STAT/E� and FEDERAL laws. APPLICANT'S SIGNATURE: 1 - DATE: ()7-1 I -14 PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 0 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. EHD 48-02-025 07/17/08 SR FORM (Golden Rod)