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SAN JOAQUIN rOUNTY ENVIRONMENTAL HEALT" EPARTMENT Q 0 SERVICE REQUEST Type of Business l Property Retail Fuel CHECK if BILLING ADDRESS ❑ j/� !T FACILITY ID # _ Co -7 3S� SERVICE REQUEST # f��`�q�� (�CEH•ECK OWNER / OPERATOR 7 -Eleven Inc. HOME Or MAILING ADDRESS P.O. Box 1025 If BILLING ADDRESS ❑ FACILITY NAME 7 -Eleven #2368-32262 Date Service Complete already completed): CITY West Sacramento SITE ADDRESS 2360W Street Number Direction Grantline Road Street Name Payment Date Tracy CI 5376 PZIPCode HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE M EXT. APN # LAND USE APPLICATION # PHONE R ) EXT. BOS DISTRICT LOCATION CODE77 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dul c inea Webb CHECK if BILLING ADDRESS ❑ BUSINESS NAME Walton Engineering, Inc. ACCEPTED Y: PH9gC 373-1166 EXT' HOME Or MAILING ADDRESS P.O. Box 1025 EMPLOYEE M Z FAX (916)373-1172 Date Service Complete already completed): CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Lt-/ DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT[]: Compliance Manager IfAPPLrcANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. - -i -- TYPE OF SERVICE REQUESTED:bf COMMENTS: F�f F4!#N EN�N'V`11R0� N1E-14 �� 'V`11 Ir�f�q)��'i��it_ � � aE-A� i f"LiliYls(/rn.— EKTALTY + �.��'F-NT NT ACCEPTED Y: EMPLOYEE M DATE: a ASSIGNED TO: EMPLOYEE M Z DATE: Date Service Complete already completed): SERVICE CODE: P / E: 2-309 Q Fee Amount: 5 Amount Paid 3 4 S _ Payment Date Payment Type Invoice # Check # 2 rJ Received By: _ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003