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SAN JOAQUIN 101UNTY ENVIRONMENTAL HEALTH D ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven #20632 <br /> SITE ADDRESS 4627 1 Da Vinci Ave FStockton 95207 <br /> Street Number Direction Street Name city FZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 E7APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Exr_ BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME or MAILING ADDRESS P.O. Box 1025 FAx <br /> 916) 373-1172 <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,STATE 4 d FEDERAL laws. _ <br /> APPLICANT'S SIGNATURE: / h �j ,f _ y <br /> DATE: 2 v <br /> I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 DEPARTMEN"C 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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />