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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> Convenience Market �� �g� C7 S9-•OD7? <br /> OWNER/OPERATOR <br /> CAGasoline Inc CHECK O BILLING ADDRESS❑ <br /> FACILITY NAME 7 Eleven 2369-39858A <br /> SITEADDRESS 2115 W Yosemite Ave Manteca 95337 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESSlIf Different from Site Address) <br /> P.O.BOX 219088 <br /> Straet Number Street Name <br /> CITY Dallas STATE TX ZIP 75221 <br /> PHONE#t EZ. APN# -7Dr;t LAND USE APPLICATION# <br /> PHQNEV <br /> E.T. �O[ BOS DISTRICT LOCATION CODE <br /> ( V )L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME D, /pin �i p PHONE# ExT. <br /> HOMEAILINGADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 tiff work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE a F ERAL .ws. <br /> APPLICANT'S SIGNATURE: DATE: lih <br /> PROPERTY/BUSINESS OWNERW OPE OR/ NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPc1C1NT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availahle and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: elvpA <br /> COMMENTS: NEP 12 <br /> 2017 <br /> %JQJQ <br /> N�rki ON Nry <br /> ACCEPTED BY: ',e' EMPLOYEE M DATE: f3 -3�-/7 <br /> ASSIGNED TO: 1 ). J/) EMPLOYEE DATE: 9-�;�_ / <br /> Date Service Completed (if already completed): SERIACECODE: ;� PIE: C4 <br /> Fee Amount: C - ai; Amount Paid I Payment Date <br /> Payment Type CYv Invoice# Check# 3s3Z Rece ved By: <br /> 69L— <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />