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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 0 [&o'2) H <br /> Type of Business or Property 1:6 CILITY ID#(� ER�V CE REQUE T# <br /> Existing 7-Eleven 00 �I - I 11,54S a-�� <br /> OWNER/OPERATORr CHECK If BILLING ADDRESS® <br /> 7-Eleven, Inc. R ( { S4 rn.a I /1 <br /> FACILITY NAME r lOj L �1 1 Q✓e' 1 m t <br /> 7-Eleven <br /> SITE ADDRESS 3040 SIV Benjamin Holt Stockton 95219 <br /> Street Number Direction treat Na a 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 /> (Zvi) CI3 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mia Rondone CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# En. <br /> Permit Place 661 1857 5620 <br /> HOME or MAILING ADDRESS FAx# <br /> 13400 Riverside Dr#202 ( 1 <br /> CITY Sherman Oaks STATE CA Zip 91423 <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, '-an EUERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/06/20 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® Permit Expediter <br /> If APPLICANT is not the BILLING PARTY Proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 availablntame time it is <br /> provided to me or my representative. NT <br /> TYPE OF SERVICE REQUESTED: Plan Check vt�D <br /> COMMENTS: 0C 7 13 2020 <br /> ISAN JOAQUIN C <br /> Equipment change for existing 7-Eleven. HEEF 1H p Pq�oq�TY <br /> rY) 1"On <3 one' � PerM4-PZA60_ • co.,� MENT <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 10-13-20 <br /> ASSIGNEDTO: Vidal PedraZa EMPLOYEE#: 6213 DATE: 10-13-20 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Paid q&p.()6 Payment Date !Y/3AD 07' <br /> Payment Type Invoice# Check# $'3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />