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SAN JOAQU BOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# II SERVICE REQUEST# <br /> retail gas station ✓}�� Q C? 0A 1 l� �4 DO &$q 1-3- <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven#19976 <br /> SITE ADDRESS <br /> "'9' N- Main Street Manteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> ( ) e2U 3 �1/tGlvt' cz <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. <br /> (916)373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( ) <br /> 73-1173 <br /> CITY West Sacramento STATE CA ZIP <br /> 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 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: - &",. DATE: 11101/7.013 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Contractor <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: is PAYIwEN <br /> COMMENTS: NE p <br /> NOV 0 3 2013 <br /> AQP <br /> Eh"V7RO,V,4 C00" <br /> e'AARrUEM <br /> ACCEPTED BY: l EMPLOYEE#: -7 0 DATE: /11013 <br /> ASSIGNED TO: l EMPLOYEE#: JDv I DATE: <br /> Date Service Completed (if already completed). SERVICE CODE: PIE: U <br /> Fee Amount: Amount Pai E75.6D Payment Date <br /> Payment Type Invoice# Check# 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />