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SAN JOAQIOCOUNTY ENVIRONMENTAL HEALTHI&PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />c <br />� <br />5/L-ae <br />OWNER /OPERATOR <br />CHECK <br />Quik Stop Markets, Inc. <br />if BILLING ADDRESS <br />FACILITY NAME <br />P.O. Box 1025 <br />Quik Stop #120 <br />(916 ) 373-1173 <br />SITE ADDRESS 9321 <br />STATE CA ZIP 95691 <br />Thornton Road <br />I <br />DATE: <br />Stockton <br />95209 <br />Street Number <br />Direction <br />Street Name <br />Date Service Completed (if already completed): <br />City <br />Zlo Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4567 <br />Fee Amount:Amount <br />Enterprise Street <br />Street Number <br />Street Name <br />CITY Fremont <br />STATE CA ZIP <br />94538 <br />PHONE #1 ExT. <br />( ) <br />APN # <br />ec ived By: <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Veronica Freitas <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />c <br />PHONE # ExT. <br />Walton Engineering, Inc. <br />916 373-1167 <br />HOME or MAILING ADDRESS <br />HEgl�QO AR ���'TY <br />FAX # <br />P.O. Box 1025 <br />(916 ) 373-1173 <br />CITY 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 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 JOAQUA <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />,(klse DATE: 4/12/14 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT EX Contractor <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 to me Or <br />my representative. PAy,,c. <br />TYPE OF SERVICE REQUESTED: (,t�S TLST-X-Z <br />CFI VF <br />COMMENTS: <br />c <br />HEgl�QO AR ���'TY <br />ACCEPTED BY: <br />EMPLOYEE #: �4, <br />DATE: <br />ASSIGNED TO: - C ri—� <br />EMPLOYEE #: 416J(. <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/ <br />PIE: ,;Z J0 d <br />Fee Amount:Amount <br />Pai 37S U� <br />Payment Date �[ <br />Payment Type <br />Invoice # <br />Check # IR S <br />ec ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />