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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station hA � 55 5RO5 1 <br /> OWNER / OPERATOR <br /> CHECK if B{I.I.ING ADDRESS <br /> Speedway LLC <br /> FACILITY NAME <br /> Speedway #4612 MINIMUM <br /> SITEADDREss 2448 W Kettleman Lane Lodi 95242 <br /> adev%as# Numbor 0 an City <br /> HOME or MAILING ADDRESS (If Different from Site Address) P . O . Box 1510 <br /> Street Numbor Street Nam <br /> CRY STATE zip <br /> MENNEN Springfield OH 45501 <br /> PHONE #1 Eve APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ErT• SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> MINIMUM <br /> REQUESTOR CHECK if BILLINQ ADDRESS <br /> Veronica Freitas <br /> BUSINESS NAME PHONE # ' <br /> Walton Engineering, Inc . ( 91 373 - 1166 <br /> HOME or MAILING ADDRESS FAx # <br /> P . O . Box 1025 ( ) <br /> Cm West Sacramento STATE CA ZIP <br /> 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: Veronica Freitas DATE; 12 / 15 /23 <br /> PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER O OTHER AUTHORIZED AGENT El Contractor <br /> 1f APPLICANT 1s not the BfLUNG 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 environmentaVsite 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. <br /> TYPE OF SERVICE REQUESTED: P <br /> COMMENTS: ECEIVED <br /> DEC 19 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> n ,� HEALTH D�PARTMENI <br /> ACCEPTED BY: , EMPLOYEE #: DATE: / 2 / t5 <br /> ASSIGNED TO: V11 k, <br /> _ EMPLOYEE #: DATE: /Z- 1 J g3 <br /> Date Service Completed (If already co eted): SERVICE ConE: P 1 E: <br /> NOW <br /> Fee Amount: Amount Paid Payment Date lANNE <br /> �/ 2� <br /> Payment Type V �j Invoice # C ck # I l sit? Received By: <br /> NOW <br /> EHD 48-02025 SR FORM (Golden Rod) <br /> 07/17/08 <br />