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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> VICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> Retail Fuel <br /> OWNER/OPERATOR <br /> New West Stations CHECK if BILLING ADDRESS <br /> FACT Rew FWest #1003 <br /> SITE AD <br /> �19$ W Banner Road Lodi 95242 <br /> Street Number I 121rection Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. qpN# LAND USE APPLICATION <br /> ( 91� 443-0890 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK ifBILLiNGADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . P"t# 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 SIGNAT <br /> � L, DATE: Eo "2, 'U j <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT 9 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�r ,i� assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at e it is <br /> provided to me or my representative. j <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: B /h <br /> 200 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARNENT <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> ASSIGNED TO: EMPLOYEE : DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: { P 1 E: _ <br /> Fee Amount: �` Amount Paid Payment Date <br /> Payment Type u Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />