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SAN JOA0*COUNTY ENVIRONMENTAL HEALTH*PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station � Ort. I' O , OWNER / OPERATOR HOME or MAILING ADDRESS Ru inder Padda P.O. Box 1025 CHECK If BILLING ADDRESS FACILITY NAME CITY West Sacramento STATE CA ZIP 95691 Count side 76 ASSIGNED TO: yf l ALL l__ SITE ADDRESS 14971 1 NI Highway 88 Lodi 95240 Street Number Direction Amount Paid Street Name Payment Date ) 0/) � 13 Citv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # 47/04:;, Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT• BOS DISTRICT LOCATION CODE �y I CONTRACTOR/ SERVICE REQUESTOR REQUESTOR P Veronica Freitas CHECK if BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. Ort. I' O , PHONE # EXT. (9161373-1167 HOME or MAILING ADDRESS FAX # P.O. Box 1025 (916) 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. 1 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, TATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATES: 10-09-2013 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Q _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 to 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: I`7 -C �� l P COMMENTS: IQ�C'tn Ir Ort. I' O , ft N�N� Ny ACCEPTED BY: l� % ` lY l EMPLOYEE #: DATE: , GI CA f l ASSIGNED TO: yf l ALL l__ EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: ; cli P 1 E: Fee Amount: -� 7 O� Amount Paid 37cS61> Payment Date ) 0/) � 13 Payment Type Invoice # Check # 47/04:;, Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08