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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Retail Fuel <br />cd -C <br />L <br />OWNER / OPERATOR <br />CHECK if BILLINGADDRESS❑ <br />Quik Stop Market, Inc. <br />FAX# <br />FACILITYNAME Quik Stop ##120 <br />DATE: <br />SITE ADDRESS <br />CIN West Sacramento <br />STATE CA ZIP 95691 <br />P I E: �f , <br />Fee Amount: ? <br />9321 <br />31 G. vv <br />Thornton <br />4tlagame <br />Stockt@ <br />�15c2o�e9 <br />Street Number <br />Direction <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 510) 657-8500 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Dul c inea Webb <br />CHECK if BILLING ADDRESS <br />BUSINESSNAME Walton Engineering, Inc. <br />PHIN�l-1166 EXT' <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />FAX# <br />P.O. Box 1025 <br />DATE: <br />(916)373-1172 <br />CIN West Sacramento <br />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 <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: L-" DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Compliance Manager <br />IfAPPLlcANT 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />R EC Ei -E® <br />APR 01 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRON VENIAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: �f , <br />Fee Amount: ? <br />Amount Paid <br />31 G. vv <br />Payment Date � I / f 0 Cl <br />Payment Type ✓ <br />Invoice # <br />Check # L. o q � ,g <br />Received By: Lj <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />