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SAN JOAQI -OUNTY ENVIRONMENTAL HEALTt :PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store r g �2ODlo Q//9 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 7-Eleven Inc. <br /> FACILITY NAME 7-Eleven Store#21756 <br /> SITE ADDRESS 853 E Yosemite Manteca 95336 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1722Routh St#1000 <br /> Street Number Street Name <br /> CITY Dallas STATE TX ZIP 75201 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (972 ) 828-7011 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Josh Hargrave CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Powerhouse Retail Services 817 297-8575 <br /> HOME or MAILING ADDRESS FAX# <br /> 812 S Crowley Road Suite A ( 817 ) 297-8576 <br /> CITY Crowley STATE TX Zip 76036 <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, S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/1/2014 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> lfAPPL/CANT is not the BILLING P.4XTY,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 COUNTS'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: ot� /z.�►y-� C ��` y�j <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M 9eoLf 9 DATE: <br /> ASSIGNED TO: 1�9(6 Q1j✓A EMPLOYEE M J`3GG DATE: -2-12S-1-111 2 - 1T <br /> Date Service Completed (if already completed): SERVICE CODE: s P I E: /(o p/ <br /> Fee Amount: --oo Amount Paid 375-.v-) Payment Date <br /> Payment Type Invoice# Check#1.2- 1 Rece ved By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />