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SAN JOAQUI&OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gasoline dispensing facility <br /> OWNER/OPERATOR 7-Eleven, Inc. CHECK if BILLING ADDRESSO <br /> FACIUTrNAME 7-Eleven S# 35355 <br /> SITE ADDRESS 3202 West Hammer Lane Stockton 95209 <br /> Street Number Dlrectlon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P. O. Box 711 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dallas TX 75221 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (714 > 771-5484 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Walton Engineering, Inc. CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ems. <br /> Walton En in rim Inc. ( 916) 373-1165 <br /> HOME or MAILING ADDRESS FAX# <br /> Post Office Box 1025 ( 916) 373-1173 <br /> CITY West Sacramento STATE CA ZIP 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 <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,SAT and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: "►L U ;�} —` DATE ~a I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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. -� <br /> TYPE OF SERVICE REQUESTED: 6157-- <br /> COMMENTS: <br /> CSTCOMMENTS: <br /> J110AQUIN CSA TM <br /> SANENV1RpOEPP.P�EWT <br /> N�-TM <br /> ACCEPTED BY: C,[� EMPLOYEE#: 903-T, DATE: /0/3/Z/ <br /> ASSIGNED TO: �S EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /GJ P 1 E:,23o� <br /> Fee Amount: <—O 0 Amount Paid t 3 S p Payment(Date p 311 l ' <br /> Payment Type Invoice# Check# LEWM. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />