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f Iq <br />SAN JOAQUI OUNTY EN'AROWENTAL HEALT EPARTMENT <br />SERVICEAZEQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />Retail Fuel <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />(� � �' <br />373-1173 <br />S, 41-00_5C/ "i& <br />OWNER i OPERATOR <br />ZIP 95691 <br />EMPLOYEE M Lt (,,3 G <br />DATE: 311--5-If <br />S f Q <br />Date Service Completed (if already completed): <br />SERVICE CODE:V <br />1 r1< <br />PIE: <br />g <br />CHECK If BILLING ADDRESS <br />FACILITY NAME CRLLC <br />#2705448 <br />Payment Date <br />3 S <br />Payment Type <br />SITE ADDRESS 1403W <br />Invoice # <br />Country Club Blvd. <br />Received By: <br />Stockton <br />95210 <br />Street Number <br />Direction <br />Street Name <br />city <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 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />l ) <br />( 2-3- Z 3 7- <br />PHONE #Z <br />EXT. <br />BOS DISTRICT / <br />LOCATION�CjODE <br />( 1 <br />l <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Dulcinea Covan - Compliance Manager <br />CHECK if BILLING ADDRESS <br />BUSINESSNAME Walton Engineering, Inc. <br />PHONE# <br />91 <br />EXT. <br />373-1166 <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />FAX# <br />( 91Cy <br />373-1173 <br />CIN West Sacramento <br />STATE CA <br />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 <br />or activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE- DATE: <br />--� <br />PROPERTY /BUSINESS OWNER ❑ "' OPERATOR /MANAGER ElOTHER AUTHORIZED AGENT Compliance Manager <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 <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. ,Q_Z_,r4L,6 Fk `/ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />VIE ENO U1L__1\01L_U V1 LL=LL2J <br />MAR 15 2010 MAR 1 5 2010 <br />SPNEN�IRONME [TA QNI�ENT HEALTH <br />H -M DEPAR OVISERVICES <br />� <br />ACCEPTED BY: <br />0 L/ F_ A2_,A� <br />EMPLOYEE 03 Z_( <br />DATE: 3 AJ- I <br />ASSIGNED TO: <br />g <br />EMPLOYEE M Lt (,,3 G <br />DATE: 311--5-If <br />S f Q <br />Date Service Completed (if already completed): <br />SERVICE CODE:V <br />1 r1< <br />PIE: <br />g <br />Fee Amount: <br />3 <br />Amount Paid S .-_ <br />Payment Date <br />3 S <br />Payment Type <br />✓ <br />Invoice # <br />Check # 2 L,( <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />