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SAN JOAQU:OUNTY ENVIRONMENTAL HEALTH &ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />3773 <br />-S4 A wk <br />V J0 ?O�L <br />5200 (V 119 (0 <br />OWNER /OPERATOR <br />9 <br />ly $ lR hUM COU <br />�oe�8 4 <br />Van De Pol Enterprises - Pacific Pride <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME <br />FAX # <br />Pacific Pride <br />SITE ADDRESS <br />CITY West Sacramento <br />STATE CA ZIP 95620 <br />DATE: <br />ASSIGNED TO: <br />351 <br />N. <br />Beckman Road <br />DATE: I Z <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />Amount Paid 375,00 <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # �E 2 <br />Street Number <br />eceived By: <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT• <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REOUESTOR <br />CHECK it BILLING ADDRESS <br />Veronica Freitas <br />COMMENTS: <br />BUSINESS NAME <br />-S4 A wk <br />V J0 ?O�L <br />PHONE# EXT. <br />Walton Engineering, Inc. <br />9 <br />ly $ lR hUM COU <br />�oe�8 4 <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />,' <br />FAX # <br />P.O. Box 1025 <br />(916)373-1173 <br />CITY West Sacramento <br />STATE CA ZIP 95620 <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: DATE: 06/30/2014 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 1Z Contractor <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the sage time it is provided to me or <br />my representative.Ab <br />q <br />TYPE OF SERVICE REQUESTED: �S7' <br />� 7 <br />ENFO <br />COMMENTS: <br />-S4 A wk <br />V J0 ?O�L <br />9 <br />ly $ lR hUM COU <br />�oe�8 4 <br />,' <br />ACCEPTED BY: �� �� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: I Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: / /1 �/ <br />P i E: 23 d 8 <br />Fee Amount: i <br />Amount Paid 375,00 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # �E 2 <br />eceived By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) j <br />vC�C' ,1 <br />