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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALT>�EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �jSERVICE REQUEST# <br /> Retail Fuel FA rm ' <br /> OWNER/OPERATOR <br /> New West Stations CHECK if BILLING ADDRESS❑ <br /> FACILReWnTest #1003 <br /> SITE ADD jE W Banner Road Lodi 95242 <br /> 6`�3 / Street Number I Direction Street Name —city Zip Code <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 /> ( 91� 443-0890 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . P§ori 373-1166 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 1916 ) 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: (o -2 'o� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTS 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 environme e assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a it is <br /> provided to me or my representative. w <br /> TYPE OF SERVICE REQUESTED: '0V <br /> COMMENTS: <br /> RECEIVE p° /�o <*,9 �J <br /> JUN 0 9 200 <br /> 9 <br /> SAN JOAQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 7301b <br /> DATE: <br /> ASSIGNED TO: CAC <br /> ApIl EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: _ U <br /> Fee Amount: 3 r� H Amount Paid 31S'\. c7 Payment Date <br /> Payment Type Invoice# Check# Received By:-��_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />