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SAN JOAQV COUNTY ENVIRONMENTAL HEALTH 0CPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK H BILLING ADDRESS <br />SERVICE REQUEST # <br />Retail Fuel <br />ASSIGNED TO: <br />If <br />DATE: <br />OWNER / OPERATOR <br />5"r� Qa`FIECK If BILLING ADDRESS <br />7 -Eleven IriC. <br />Fee Amount: <br />FAauTrNAME 7 -Eleven 42368-32262 <br />373-1173 <br />SITE ADDRESS 2360W <br />STATE CA <br />Grantline Road <br />Received By: <br />Trac yfUN <br />O-,1 <br />953"'�*Fs <br />Street Number <br />Direction <br />Street Nam <br />Ci <br />f Code <br />10 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />m," @ <br />STATE <br />CITY <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # ' <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />CHECK H BILLING ADDRESS <br />Dul c ine a Webb <br />DATE: <br />ASSIGNED TO: <br />BUSINESS NAME Walton Engineering Inc. <br />DATE: <br />PHONE # <br />91§ <br />EXT' <br />373-1166 <br />HOME or MAILING ADDRESSFAX <br />PO BOX 1025 <br />Fee Amount: <br /># <br />( 91(1 <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />ZIP 95691 <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 />1 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, Standar s STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 6-8-10 <br />PROPERTY/ BUSINESS OWNER❑ OPERA'rOR/MANAGER❑ OTHERAUTIIORIZEDAGENT13 Compliance Manager <br />If APPLICANT is not the BILLING PART)', 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 available and at the same time it is <br />nrovidpri to me nr my representative. <br />r.....--- -- ---- -_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />FILA <br />COPY <br />