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SAN 3OAQUIW'-' UNTY ENIVIjONMENTAL HEALTWPARTMENT SERVICE REQUEST rType of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # Retail Fuel r1W7V106 0 Q�� f•� OWNER/ OPERATOR CHECK If BILLING ADORES Quik Stop Market, Inc. CITY West Sacramento FACILITY NA E Quik Stop #76 ZIP 95691 SITE AQp5F, b 11 33 1111 S I Olive Avenue Stockton 95215 Street Number Direction Street Name DATE: 7 v a cityZI Code HOME Or MAILING ADDRESS (If Different from Site Address) 7 Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # � 51 657-8500 15 7- 2-f;`A- tea- ..- PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) 0 Check # CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Webb �e`�Yo};� T-ctic 11 k 04r— CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. COMMENTS: COMMENTS: P 373-1166 EXT. HOME or MAILING ADDRESS P.O. Box 1025 FAX # 1916) 373-1173 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: --- 11L� DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT L? Compliance Manager_ 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: �S� �e`�Yo};� T-ctic 11 k 04r— COMMENTS: COMMENTS: N AAN SH EN\JIRDNMEN T JOA\QL) ' `pEN HEALTMDEPAR ACCEPTED BY: EMPLOYEE #: DATE: 7 v a ASSIGNED TO: EMPLOYEE #: Lt Date Service Completed (if already ompleted): SERVICE CODE: J 9 P 1 E: 3® Fee Amount: ( o Amount Paid 3 Z Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003