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SAN JOAACOUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property Iy YMFN FACILITY ID # SERVICE REQUEST # gas station SA1y �0 Z0,7 gQUi PHONE # Ex -r. -Sl 4U ( ,I q V g OWNER /OPERATOR CHECK Quik Stop Markets, Inc. if BILLINGADDRESSO FACILITY NAME P.O. Box 1025 Quik Stop #148 (916 ) 373-1173 SITE ADDRESS 205W STATE CA ZIP 95691 Lockeford Street PIE: Lodi 95240 Street Number Direction Street Name Invoice # Cit ZI Code HOME or MAILING ADDRESS (if Different from Site Address) 4567 Enterprise Street Street Number Street Name CITY Fremont STATE CA ZIP 94538 PHONE #1 Err. ( ) APN # LAND USE APPLICATION # PHONE #2 Exr. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Iy YMFN Veronica Freitas CHECK if BILLING ADDRESS® BUSINESS NAME Walton Engineering, Inc. SA1y �0 Z0,7 gQUi PHONE # Ex -r. E,y Al 916 373-1167 HOME Or MAILING ADDRESS EMPLOYEE #: FAX # P.O. Box 1025 EMPLOYEE #: /�/�/ (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. 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 4/12/14 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 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 to me Or my representative. TYPE OF SERVICE REQUESTED:us cT/'r-+J f= % Iy YMFN COMMENTS: O FQ �' 16 SA1y �0 Z0,7 gQUi E,y Al ACCEPTED BY: t.j EMPLOYEE #: DATE: ASSIGNED TO: //e-: L EMPLOYEE #: /�/�/ DATE: 7 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: 3 5 – Amount Pal 7S lnrj Payment Date Payment Type Invoice # Check #zz— 'tDo Fllece4ved By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08