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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gasoline dispensing facility �S !� -,t;7711- <br /> OWNER <br /> ,t; 1OWNER/OPERATOR <br /> Sean Kapoor CHECK If BILLING ADDRESS 10 <br /> FACILITY NAME Bonf are Market #35 <br /> SITE ADDRESS 15Grantline Road Tracy 95376 <br /> er <br /> Street NumbDirection I Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 461 S . Milpitas B1Vd. , #1 <br /> Street Number Street Name <br /> CITY Milpitas STATE CA ZIP 95035 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (408) 933-4422 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE Walton Engineering, Inc. ( 916) 373-1152Exr. <br /> HOME or MAILING ADDRESS PO BOX 1025 FAx# <br /> CITY West Sacramento STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 anthat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and laws. o <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT ` S <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required SCG Ott e <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: PAY <br /> MEN I r4 5KCOMMENTS: <br /> SUN 3 0 2009 <br /> �A )AcUIN COUNTY <br /> ENVIRCDNMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already c - 22 <br /> ompleted): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid `S Payme Date 3 <br /> r <br /> Payment Type Invoice# Check# 'L Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />