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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 Store/Gas Station __7 1 suwx_q2�_ <br /> OWNER/OPERATOR 7_ElevenInc. CHECK if BILLING ADDRESS E] <br /> FACILITY NAME 7-11#32190 <br /> SITE ADDRESS4943 outh Hwy 99 Stockton 95215 <br /> Street Number DSirectionF Street Name city Zin Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 3200 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 /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Rich Shoemaker <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME powerhouse PHONE# EXT. <br /> t 817-297-8575 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 HEALTA 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 applic tl a the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA 1 I D.RAI , <br /> APPLICANT'S SIGNATURE: DATE. T— I S—�iC} <br /> - <br /> —t-- <br /> PROPERTY/BUSINESS OWNER❑ OPERA7PARproof <br /> OR/ GER ❑ OTHER AUTHORIzEDAGENT�lleCtOr <br /> JfAPPLlCANT is nol the BILLINof authorization to sign is required Title <br /> AU`T'HORIZATION TO RELEASE INFON: 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„at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: plan Review Roller Grill Conversion <br /> COMMENTS: <br /> M <br /> ACCEPTED BY: /'_Z t-Y-�2� LG I EMPLOYEE#: DATE: `7_ t y <br /> ASSIGNED TO: �'G-•!I til tJ3 G v EMPLOYEE#: DATE: ,7''-t J—( <br /> Date Service Completed (if already completed): SERVICE CODE: �Z� P I E: &O f <br /> Fee Amount: c�S1-1 � Amount Pai ��� u� Payment Date ?�� <br /> 12 <br /> Payment Type Invoice# Check# 35� Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 7/2 003 <br />