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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel 206 '5'e � 3 <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 7-Eleven #2369-14117 <br /> SITE ADDRESS 2725 Country Club Lane Stockton 95201 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CIT, STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> 1 } <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan - Compliance Manager CHECK if BILLING ADD RESS <br /> BUSINESS NAME PHONE# Ems' <br /> Walton Engineering, Inc _ 91 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.C. Box 1025 ( 91q 373-1173 <br /> CITY West Sacrament© STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE:, DATE: <br /> Compliance Manager <br /> PROPERTY/BUSINESS OWNER[] OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 6 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 DEPARTMENT 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: �'S 1Cr��/�f r PAY Ivy E NT <br /> HEUEUED <br /> COMMENTS: <br /> AUG 2 4 2011 <br /> SAN JOACIUfN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: qo'�g DATE: g !! <br /> ASSIGNED TO: r UGC'-'+ EMPLOYEE#: 142--1 DATE: li <br /> Date Service Completed (if already completed): SERVICE CODE: G� P I E:'�- '34 <br /> Fee Amount: � � Amount Paid Payment Date $ // <br /> Payment Type �/ Invoice# Check# eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />