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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 F vaboo(aoc) S � O� � yt n � <br /> OWNER / OPERATOR <br /> Flyers Energy, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Flyers #427 <br /> SITE ADDRESS <br /> 3300 Waterloor Rd . Stockton 95205 <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 /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 /> PO Box 1025 ( 916 ) 373- 1172 <br /> � T <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 /> 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 : A/lSX10 DATE : Z <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ 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 is provided to me or <br /> my representative . IJAY <br /> TYPE OF SERVICE REQUESTED : � ' � ie' V <br /> COMMENTS : <br /> SAN JOA DEC 15 2021 <br /> QUIN CO <br /> HEALTH pEAHTM NTy <br /> 9 , ENT <br /> ACCEPTED BY : /r \ /��� Co� EMPLOYEE # : DATE : <br /> ASSIGNED TO : I �\ �� V)C:77Q do EMPLOYEE # : DATE : 1.211 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIS 29749 P I E : <br /> Fee Amount. P4/&7099 cc Amount Pai qS , 0 Payment Date / �s <br /> Payment Type Invoice # Check # SG Received By • <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />