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SAN JOAQO COUNTY ENVIRONMENTAL HEALT PARTMENT O Type of Business or Property FACILITY ID # SERVICE REQUEST # retail gas station DATE: PHONE # OWNER /OPERATOR CHECK if BILLING Date Service Completed (if already completed): ADDRESS FACILITY NAME HOME or MAILING ADDRESS Olympian #487 FAx # SITE ADDRESS 983 I Moffat Blvd I Manteca J 95336 Street Number Direction (91 Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2360 Lindbergh Street Street Number Street Name CITY Auburn STATE CA ZIP 95336 PHONE #1 EXT• ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR SERVICE• OV REQUESTOR Veronica Freitas COMMENTS: CHECK if BILLING ADDRESS® BUSINESS NAME DATE: PHONE # EXT. Walton En ineerin Inc. Date Service Completed (if already completed): (91Q 373-1167 HOME or MAILING ADDRESS Amount Paid FAx # Payment Type P.O. BOX 10 2 5 Check # Received By: (91 373-1172 CITY West Sacramento STATE CA ZIP 95691 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 00-20-1-1 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® (,on t- Ya _ .OY 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: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: p / E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 07/17/08 SR FORM (Golden Rod)