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SAN JOAQUII&OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CONVENIENCE STORE WITH GAS FA0002541 n6b�� <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc . CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven Store 20632 B/2237 <br /> SITE ADDRESS <br /> 4627 Street Number I Direction DA V I NCsget QgI VE S TOC i TON 9 Z2 07 <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> PO BOX 711 ATTN: ENV I RO . DEPT.Street Number Street Name <br /> CITY DALLAS TXTE zip <br /> 75221 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 952-3543 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (714 ) 771-5484 11 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: a � '" ��'`= DATE: 12/6/2012 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER AtiTHORIZ.ED AGENT® REG. ENV. COMP. SPCLST. <br /> ]fAPPLICANT 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 JO,AQUIN COUN'i'v ENVIRONMENTAL.HI.;AL'ni 13E3PARTME:NT 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: PAYMENT <br /> ry <br /> COMMENTS: RECEIVED <br /> DEC 1 4 2012 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HE F-PARTMENT <br /> ACCEPTED BY: IAF EMPLOYEE#: DATE: n� <br /> ASSIGNED TO: 'Osf Gvu 5 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I E: IS <br /> Fee Amount: &V t Amount Paid �L` ©� Payment ate <br /> Payment Type V Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />