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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Dispensing Facility rd /7002 2 ea <br /> C <br /> OWNER / OPERATOR /� v J <br /> Quik Stop Markets , Inc. CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Quik Stop # 132 <br /> SITE ADDRESS <br /> 3555 W. Hammer Lane Stockton 95219 <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 /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Sarah Jablonsky-Construction Manager <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc. 916 373- 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> �P�TOYBox 1025 ( 916 ) 373- 1172 <br /> 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 : � �y�(� , DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER u OTHER AUTHORIZED AGENT ❑ 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 same time It Ipr ided to me or <br /> my representative . ' `1 A <br /> TYPE OF SERVICE REQUESTED : S �� <br /> COMMENTS: A � 0 <br /> JJ <br /> S�NVRoU/NC202> <br /> CTyD pgRT����f' <br /> ACCEPTED BY : SyLa CZ4 � EMPLOYEE # : DATE: 2 7 . � / <br /> ASSIGNED TO : EMPLOYEE # : DATE: /� �/ <br /> Date Service Competed ( if already completed ) : - — SERVICE CODE: / PIE : 3D�% <br /> Fee Amount : G9 Amount Pai / -S(�� d Payment Date <br /> Payment Type =� C!/ Invoice # Check # S7 �D Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />