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SAN JOAQUIN . OUNTY ENVIRONIIO'ENTAL HEALTH EPARTMENT <br /> I it <br /> SERVICE ]REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#O-5 <br /> Retail Fuel �-� gep_ CO-5-9-51 <br /> OWNER/OPERATOR <br /> Quik Stop Market, Inc. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Quilt Stop #148 <br /> SITE ADDRESS 205 WLockeford Street Lodi 95240 <br /> Street Number Irectlon Street NameCI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 519 657-8500 041 _ 1(p(_(.S- <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Walton Engineering, Inc. P 373-1166 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 016 ) 373-1173 <br /> CITY West Sacramento 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: � DATE: <br /> ' l 05 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L? Compliance Manager <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 <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 t' It is <br /> provided to me or my representative. YN1EN <br /> TYPE OF SERVICE REQUESTED: Rn M <br /> S-1— ��r•J(— ,4 t ,� RE <br /> COMMENTS: 1� 1 <br /> coUNn <br /> 5 E P 1 4 20 9'ENv R NYME""- <br /> H�TH DEPARSME <br /> ENVIRONMENT HEALTH <br /> RERA <br /> ACCEPTED BY: o L-( v ( ,/� EMPLOYEE#: z-2-1 <br /> DATE: 7A' / <br /> �s U <br /> CA <br /> -,"*I TO: ti7— ` EMPLOYEE#: ! 4-Z-2 DATEO <br /> Date Service Completed (if already completed): SERVICE CODE: L1 � <br /> Fee Amount: �cF$, Amount Paid �(,� Payment Date �y (� <br /> Payment Type \/ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />