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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel �� sy? 3 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 7-Eleven #2368-32190 <br /> SITE ADDRESS 4943 S State Hwy 99 Stockton 95215 <br /> Street Numtrer DI cao <br /> t Na a CI ZI Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) p.0. Box 711 <br /> Street Number frost Name <br /> STATE ZIP <br /> CITY <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 EM BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS <br /> Dulcinea Covan - Compliance Manager <br /> NE# EZT. <br /> BUSINEssNAME Walton Engineering, Inc. PHONE373-1166 <br /> HOME or MAILING ADDRESS FAx# <br /> p.0. Box 1025 ( 91§ 373-1173 <br /> CITY 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 <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 SIGNAT,;�- ' /t ���� DATE: o1-a(O - I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Compliance 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 <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 /> � . REDENED <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: SGP 211 <br /> SANE,H RONM TM <br /> HEALmI DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: i <br /> EMPLOYEE#: �� DATE: <br /> ASSIGNED TO: LLL <br /> SERVICE CODE: t' P/E1 <br /> Date Service Completed (If already completed): 1 tl <br /> Fee Amount: I Amount Paid `S 37SS- 0 D Payment Date 9 �/ <br /> Payment Type ✓ Invoice# Check# Lf({ Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />