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SAN JOAQUIN .'OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Commercial FA0003124 �4,W -7o(f%1� <br /> OWNER/OPERATOR TEJ Trading, Inc . CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 7 Eleven Store 42369-20304C <br /> SITE ADDRESS 455 West Grant Line Road <br /> Tracy 95376 <br /> Street Number Direction Street Name Ci Zin Code <br /> hRDNEY&MAILING ADDRESS (If Different from Site Address) Post <br /> Office BOX 219088 <br /> Street Number sA�E Street Name <br /> S <br /> CITY Dallas TXZIP 75221 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2091 835-7254 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209) 481-7445 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jivtesh Singh Gill, President CHECK if BILLING ADDRESS® <br /> Exr. <br /> BUSINESS NAME 7 Eleven Store #2369-20304C (PHONE# 835-7254 <br /> MAILING ADDRESS Post Office Box 219088 FAx# <br /> CITY Dallas STATE TX ZIP 75221 <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 applicatio/ and at the work be pe rfo a ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and ER laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ?IIWIK- <br /> PROPERTY/BUSINESS OWNER OPE O / ANAGER ❑ OT ERA TH- IZED AGENT 11hief inancial Officer <br /> If APPLICANT is not the BIL NG ARTY proof of author' ation to sign is required Title <br /> AUTHORIZATION TO RELEASE IN140 MATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the /elease 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: ton <br /> PAYMENT <br /> COMMENTS: RECH`M EL! <br /> OCT 0 G <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: M EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI <br /> Fee Amount: Amount Paid (30,O'D Payment Date to 12 Is <br /> Payment Type Invoice# Check# �Cvs� Received By: <br /> I'll VJL 4 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br />