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r <br /> SAN JOAQU96OUNTY ENVIRONMENTAL HEALTHINIPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station Fa©U a 3&L->fl S Ig 0e-7(v 512- <br /> OWNER/OPERATOR Flyers Energy,LLC. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Olympian Fl ers#427 <br /> SITE ADDRESS 3300 Waterloo Road Stockton 95205 <br /> Street Number Direction I Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2360Lindbergh Street <br /> Street Number Street Name <br /> CITY Auburn STATE CA ZIP 95602 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESSD <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. (916)373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento STATE CA 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: dam- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Contractor <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: LA S r PAYMENT. <br /> COMMENTS: iVED <br /> ND 4- �Il� - ��-l ;(�� -nFr 2 8 2016 <br /> KtUtlx <br /> 1 e," ti lk�Q ,AE WIRONM Co DEC 2 8 2016 <br /> " T <br /> EA� �CEPq TMAL <br /> ENT <br /> -RlEWA IMENIA1 LTH <br /> ACCEPTED BY: �1S EMPLOYEE#: f TMEN Z�/ <br /> ASSIGNED TO: r2l V C—T— EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: �3,� <br /> Fee Amount: ( -7 Amount Pai V7. 0Payment Date 1 ZIA� <br /> Payment Type Invoice# Ch k# C2gt-.7� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />