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SAN JOAdo COUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station -7 S9 06 7/40// <br /> OWNER/OPERATOR <br /> Quik Stop Markets, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Quik Stop#148 <br /> SITE ADDRESS 205 W. I Lockeford Street Lodi 95240 <br /> Street Number Direction Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street <br /> Street Number Street Name <br /> CITY ZIP <br /> Fremont STATE CA 94538 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento 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: A`&- DATE: 11/18/2014 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [X 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVE® <br /> NOV,2 0 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> EALTH DEPARTM NT <br /> ACCEPTED BY: EMPLOYEE#: i DATE: <br /> ASSIGNED TO: J }`�; EMPLOYEE#: PATE: T <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: U <br /> Fee Amount: Amount Paid l Payment Date It <br /> �® <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />