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SAN JOAQUVOUNTY ENVIRONMENTAL HEALTOPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS® SERVICE REQUEST # Gas Station((A�� PHONE# 91 Err. 373-1167 0 Z) 'Z 5 OWNER / OPERATOR OCT t 4 i i"03 P.O. BOX 1025 Quick Stop Markets, Inc. CHECK If BILLING ADDRESS FACILITY NAME Quick Stop # 39 ZIP 95691 ENVIROMENTAL ACCEPTED BY: SITE ADDRESS EMPLOYEE #: E. Fremont Stockton ASSIGNED TO: 95205 2285 Street Number Direction DATE: i ! 41113 Street Name Ci SERVICE CODE: �U Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Fee Amount: Z , v Amount Paid 2 .5-0 Payment Date OIC n Street Number Invoice # Street Name Check # CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT• BOS DISTRICTLOCATION CODE ( ) 61 C CONTRACTOR / SERVICE REQUESTOR REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS® BUSINESS NAME Walton Engineering, Inc. /REQUESTED: COMMENTS: % /s�O'�I,�� l/ PHONE# 91 Err. 373-1167 HOME or MAILING ADDRESS FAX # OCT t 4 i i"03 P.O. BOX 1025 (9161 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. 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: ,a" Aa-&- DATE: 10-11-13 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Contractor 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 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 my representative. TYPE OF SERVICE /REQUESTED: COMMENTS: % /s�O'�I,�� l/ OCT t 4 i i"03 SANJOAQUIN COUN ENVIROMENTAL ACCEPTED BY: EMPLOYEE #: d Jl DATE: ASSIGNED TO: EMPLOYEE M vwJL DATE: i ! 41113 Date Service Completed (if already completed): SERVICE CODE: �U PIE: C� Fee Amount: Z , v Amount Paid 2 .5-0 Payment Date OIC n Payment Type Invoice # Check # Received By: tt91t-Ay- 4 oii -5 79 EHD 48-02-025 SR FORM (Golden Rod) 07/17/08