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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SER <br /> VICE REQUEST # <br /> Retail Gas Dispensing Facility vU U 3 e � VQ 1N Do <br /> OWNER / OPERATOR <br /> Flyers Energy , LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Flyers #487 <br /> SITE ADDRESS <br /> 983 Moffat Blvd , Manteca 95336 <br /> Street Number 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 /> ( 530 ) 885 - 0401 .22 1 �Gj ,Q <br /> �7[ <br /> PHONE #2 EXT, BOS DISTRI T LOCATION C DE <br /> ( ) (20 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc . 916 373- 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 1025 ( 916 ) 373- 1172 <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 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 : �,I� I �y4 DATE : 07/23/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 Construction 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Sam time it is provided to me or <br /> my representative . PA Vill <br /> TYPE OF SERVICE REQUESTED : (i7� /�� C cElle <br /> COMMENTS: JUL <br /> 221 <br /> He N <br /> VIA <br /> ON /NCOUNT <br /> ALTH 'DEPA T L <br /> ACCEPTED BY: V � �' y � � EMPLOYEE # : DATE : <br /> ASSIGNED TO : /AiSQ EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed ) : SERVICE CODE: `qr -2� � PIEsic <br /> 8 <br /> Fee Amount: O C Amount Paid �SGv� Payment Date <br /> Vol <br /> Z <br /> Payment Type Invoice # Check # S8 L� Recei/ed By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />