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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gasoline Dispensing Facility © �) L4S ,L <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Speedway <br /> FACILITY NAME Speedway #4612 <br /> SITE ADDRESS <br /> 2448 West Kettleman Lane Lodi 95242 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # Hp11 LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Sarah Jablonsky - Construction Manager <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc. 916 373 - 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> POO. Box 1025 ( 916 ) 373- 1172 <br /> 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 : jN �I � DATE �OI Ito <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Vj Construction Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sigh 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 t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : �1 ,I A AY41ENT <br /> I <br /> COMMENTS : ' VE® <br /> AUG 12 2020 <br /> SA N OAQ IN COUNTY <br /> HEALTH DEP ENTAL <br /> ACCEPTED BY : /i �V�J fes_J EMPLOYEE # : DATE : <br /> ASSIGNED TO : �� (! (, 9 0 EMPLOYEE # : DATE : Opp � <br /> Date Service Completed ( if already completed ) '. --� � SERVICE CODE : PIE : 2 � <br /> Fee Amount : O `' Amount Paid ��� Payment Date Olt 2, ILQ <br /> Payment Type Invoice # Check # 5(o ZZ Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />