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SAN JOAQUIN COUNTIr ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store/Gas Station �7 g �� <br /> OWNER/OPERATOR 7-Eleven Inc. / CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 7-11#32190 <br /> SITE ADDRESS 4943 SoAh Hvry 99 Stockton 95215 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2200 Hackbeny Road <br /> Street Number_ _ Street Name <br /> CITY Irving STATE TX ZIP 75063 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> _ CONTRACTOR/SERVICE REQUESTOR <br /> rREQUESTOR RICh Shoemaker <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Powerhouse PHONE# ExT. <br /> 617-297-8575 X 7369 <br /> HOME or MAILING ADDRESS 812 S.Crowley Road FAX# <br /> 1 <br /> CITY Crowley STATE TX ZIP 76036 <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 1 have prepared this applic tl le work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA I I RAI .ws. t� <br /> APPLICANT'S SIGNATURE: _ DATE- <br /> PROPERTY/ <br /> ATE-PROPERTY/BUSINESS OWNER❑ OPERA OR/N % AGER❑ OTHER AUTHORIZED AGENT L Director <br /> If APPLICANT is nol the BILLING PAR proof of authorization to sign is required Tfrle <br /> AUTHORIZATION TO RELEASE 1NFORMA ION: When applicable, 1,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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and.Rt the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Plan Review Roller Grill Conversion NF <br /> COMMENTS: tb <br /> ���C,��lc �(ctv`� S,,• J�l ,6, �� <br /> 3 S } ( �> t3 1l; n�lc�F yR <br /> ACCEPTED BY: ��CJs Gp EMPLOYEE#: DATE: 7—.',r,— <br /> ASSIGNED TO: CGS-r te G� EMPLOYEE#. DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �'L3 PIE: t ao t <br /> Fee Amount: 4S W Amount PaidT620 e ?/ / <br /> Payment Type I Invoice# I Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />