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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility 0D_-7 L —7�' <br /> OWNER/OPERATOR <br /> 7-Eleven CHECK if BILLING ADDRESS® <br /> FACILITY NAME 7-Eleven#38153 <br /> SITE ADDRESS W.Market Sl. & S.Center Streeter Stockton 95202 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4637 Chabot Drive,Suite 117 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Pleasanton CA 94588 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (g2-5) 353 - -7-tde q��. �-,\\ <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Walton Engineering,Inc. CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering,Inc. 916-373-1165 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O.Box 1025 ( ) 916-373-1172 <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 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 t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and EDERAL laws. <br /> i <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER b OTHER AUTHORIZED AGENT El <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 above <br /> site address. hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S� <br /> COMMENTS: <br /> PAY 20.1 <br /> ENVIRONMENTAL HEALTH <br /> PERM!T1SERJPpv, <br /> ACCEPTED BY: C �, EMPLOYEE#: DATE: 2 S <br /> ASSIGNED TO: �l�`✓ EMPLOYEE#: DATE: S" 1 S <br /> Date Service Completed (if already completed): SERVICE CODE: O 3 P I E: <br /> Fee Amount: �/ Amount Paid ' Payment DAY <br /> Payment Type V Invoice# Check# C3 cJ bIMBy. <br /> MAY <br /> EHD 48-02-025 SAN j020 FORM(Golden Rod) <br /> yIJ <br /> 07/17/08 ENJ QUIiy CO <br /> HEAkTQpMR �7Y <br />