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S <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# T-76E—R—VIC REQUEST# <br /> Fuel <br /> OWNER 1 OPERATOR d' <br /> 7-Eleven Inc , fir" (- r # -i CHECK if BILLING ADDRESS Int <br /> FACUT�,NM.1E 7-.Eleven #2368-14117 <br /> SITEADDRFS$ 2725 Country Club Lane Stockton T95201 <br /> Street m—ber Dlreetlnrs Strout Name Cit ZIP-Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHCNE#1 ExT. APN N LAND USE APPLICATION N <br /> ( I <br /> PHC4E2 EXT. BOS DISTRICT LOCATION CODE <br /> i ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb-Govan CHECK if&LuNGADDRESS El <br /> BUSINESSNAME Walton Engineering, Inc , PHONE# E"- <br /> 916 373-_1166 <br /> HOME Or MAILING ADDRESS FAx# <br /> P.O. Box 1025 ( 9161`-373-1173 <br /> CITY West Sacramento STATE CA ZIP 95691 71 <br /> BILLING ACKNOWLEDGEIMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH D[PARTMENT hourly charges associated with this project <br /> or 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 FFDERAL laws. <br /> APPLICAN'T'S SIGNATURE ,>J, - - 1 - [r✓�- DATE: L+ l u - <br /> PRQPF.R11`/f3USIYESSOWNER❑ OeERATpItl,1'l%N GER ❑ OTHFttAt:TItQRILEDAtaEiYT� Compliance Manager <br /> II'APPLICrtx'r is not the BILLING Pr_�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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Di:PARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: r EMPLOYEE#: DATE; <br /> ASSIGNED To; EMPLOYEE#: DATE; <br /> Date Service Completed (if already completed): SERv CE Canf: P!E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-42-425 SR FORM(Golden Rod) <br /> REVISED 11117/2443 <br />