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SAN JOAQ%,WCOUNTY ENVIRONMENTAL HEALTi,,4)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 6 0 ?ice D SZ is <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> 7-Eleven, Inc. <br /> FACILITY NAME <br /> 7-Eleven #17334 <br /> SITE ADDRESS I N Pershing Avenue Stockton 95207 <br /> 4501 Street Number Direction Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209) 951-6745 <br /> PHONE#2 Ext. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> Walton Engineering, Inc, 373-1167 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 1025 (916)373-1172 <br /> CITY West Sacramento STATE CA ZIP 95691-1025 <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 SIGNATURE: / �r DATE: 07-05-12 <br /> PROPERTY/BUSINESS OWNER "'bbb OPERATOR/MANAGER OTHER AUTHORIZED AGENT L4 Contractor <br /> JfAPPLICANT 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: <br /> COMMENTS: RECEIVED <br /> JUL - 6 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVtRONMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: O <br /> Fee Amount: Amount Paid C3-1 6,0 Payment Date -7 <br /> Payment Type Invoice# Check# 4S3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />