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SAN JOAQU OUNTY ENVIRONMENTAL HEALTISPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />rj4 00(5�o �l(fI <br />SERVICE REQUEST # <br />vob jQ&;41 <br />OWNER/ OPERATOR <br />Quik Stop Market, Inc. <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME <br />Quilt Stop #124 <br />373-1166 ExT. <br />SITEADD15gs <br />Street Number <br />N <br />Direction <br />Main <br />I <br />Street <br />Street Name <br />Manteca <br />city <br />95336 <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 />( 514 657-8500 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />Payment Type <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dul c inea Covan <br />CHECK if BILLING ADDRESS E] <br />BUSINESS NAME Walton Engineering, Inc. <br />I JUN 2 2 201 <br />SAN JOAQUIN CUuwrt <br />ENNIRO00ET1�AL <br />HEJU TN DEPARENT <br />P <br />373-1166 ExT. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />DATE: 2 <br />FAX # <br />P16) <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />ZIP 95691 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or s; s _ o e r or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HE, _Tldl es associated with this project <br />or activitywill be billed to me or m J business as identified on this form. ��/ p , <br />Y <br />I also certify that I have prepared this application and that the work to be performed wpll�e &qd in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard,, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT f Comp 1 i anc e Manager <br />If APPLICANT is not the BILL/NG 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. osVMF-N'T <br />TYPE OF SERVICE REQUESTED: <br />RECENED <br />COMMENTS: <br />I JUN 2 2 201 <br />SAN JOAQUIN CUuwrt <br />ENNIRO00ET1�AL <br />HEJU TN DEPARENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />1 <br />DATE: 2 <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if 8lready completed): <br />SERVICE CODE: 51f <br />P / E: Z3og <br />Fee Amount: ° d <br />Amount Paid <br />Payment Date <br />y <br />Payment Type <br />Invoice # <br />Check # f Zg 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />