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9 • <br />RECEIVED 03{0412012 22:15 20''4f8yo0y F'AL:1(-Ir! i_,pK WASH <br />03;0512012 10.27 51E3731173 14ALTGNEIN31tZERIN(aPAGE vie, 02 <br />2" <br />SAN JOA.Q1XN COUNTY ENVIRONXENTAL UEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Proptnfy <br />FACILITY ID <br />SERVICE REQUEST I <br />Fuel <br />pwowg <br />9xr. <br />py�R�etail <br />i?acOz�i TS.- <br />4 916 <br />Wash <br />Ct�crc it �c4_It3Si <br />FAOUTY RAMS Narket Place <br />iOA'Q <br />HEALTH DEPARWF <br />4TEAoDRM 44( Pacific Avenue Stockton 95207 <br />ROME or MAa.INa AnD"SS jtt AFReru,rt huin S! W AWiWtW) <br />4 3I S Pacific A,%renue <br />CrrY <br />Stockton <br />M.af Nitmo <br />ST"TFCA Zif 5207 <br />AWAI �� <br />Fee Amount3 7 S r Ob Amount raid <br />L"D USE AapucArroN a <br />(2 <br />2091 <br />9)47E-5509 <br />Check # Rnrnt�.a ae,.• <br />PHew #2 ext' <br />t ) <br />Bos DaTwov t ocarloN CODE <br />CONTRACTOR / SV -F i2VATTL'crrnn <br />REQUESTER <br />Tanya Thompson <br />CHECKif&uJNo/ltalfl <br />ItuslNti NAME Walton EnVInee.inq, inc. <br />pwowg <br />9xr. <br />_1 <br />4 916 <br />373-1166 <br />HOW or LUuNG ADDREss <br />FAX# <br />iOA'Q <br />HEALTH DEPARWF <br />Q.O. Box 1025 <br />i 9,14 <br />373-1173 <br />Cm Iles t: Sacramento <br />SratE rA <br />ZaP 95691 <br />Li�lll{JM'LI6DC�EMF1'T; I, the undersigned progorty or businew owner, operator or nuthprired aT;etit of same. <br />acknowledge that all site and:or pmjact Specific .E.4vi R0\NE?sTALii6ALTri DT pARTMDN"r hourly charges aasoclated With this project <br />or activity will be billed to me or my business as identified on this farm. <br />I also certify that 1 havo prepared this application and thst the work to be Wormed will be done in accordance. will aU S,�Y )GAQUIi� <br />c[ lxw Ordinance Codes. slandaSTAM, and FEosRatL laws. <br />N3'f <br />APPLICAS SIGNATtIRE: CA a V `'— --- <br />Norrm"IAFsmSe()a,acxJR OrnitAToxIMAnAGAR ❑ Onrtx, Lrn0sutnAus.1-r13� <br />1f,lPPLXA.,Vris not the BZL - P_4M- proof Rf aui4nrizaaon M sign ie ttgnirpd rirre <br />$MORIZATION To RELEASE iiN1F4It.�VIA,'i<1ONt When applleabie, L tilt owner or operator of the property located at tite <br />abDve site address, hereby authorize the re(mse of any and: ail restos, geotechaioal data andior e-wimnmantal/site assessment <br />ir)formatloe to the &%N J(JAIWIN COUNTY ENVIItOwNfEhTriL t•.4=ALM- DEPAR't'Visvr as soon as it is available and u tho samo tine it i< <br />provided to rns or my representWvc. <br />jLIT <br />TYPE OF SC -fel: RmuESTED: U <br />CAtItrENT3: <br />MAR 0 5 2012 <br />SAN Ia C�O NTY <br />iOA'Q <br />HEALTH DEPARWF <br />ACciprio By: • J ISL± �, Tt 2� <br />E!lrPLOYEf >i`: �% ! OATS: S 2 <br />ASSIOHfDrO: GV� <br />EMPLDYEg>j; /_ r DATE: 3 (♦Z <br />DUO Service Completed {N already completed): <br />S M'M CODE: P 16: <br />Fee Amount3 7 S r Ob Amount raid <br />D <br />Payment Date <br />Payment Type 1� lnnoioe # <br />Check # Rnrnt�.a ae,.• <br />EHt7 43.02-025 <br />REVISF.0 Iin 7 <br />$R FORM (Golden Rod) <br />-:'0/Z0 39,:i H$tiM dH,) iI3I'trd 60sseL,t7r Z 613:x_ c'.T0Zlp13;cr:0 <br />