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'&W -4 SAN JOAQUII 'UNTY ENVIRONMENTAL HEALT"" "EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Retail Fuel CHECK If BILLING ADDRESS BUSINESS NAME ?, OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ 7 -Eleven, Inc . FACILITY NAME 372-1888 7 -Eleven #32262 APR 2 4 2009 SITE ADDRESS 2360 W I Grantline Road Tracy 95377 Street Number Direction Street Name SAN JOAQUIN COUNTY city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) HMDEI' E #: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (916) 463-6720 Date Service Completed (if already completed): SERVICE CODE: PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Walton Engineering, Inc. COMMENTS: CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. 3900 Commerce Drive 916 372-1888 HOME or MAILING ADDRESS APR 2 4 2009 FAX# APR 2 4 2009 P.O. Box 1025 (916) 373-1172 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: ��, '' - DATE: v PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Compliance Manager If APPLICANT 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 environmental/site 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. TYPE OF SERVICE REQUESTED: COMMENTS: PAYMENT RECEIVED APR 2 4 2009 APR 2 4 2009 ENVIRONMENT HEALTH SAN JOAQUIN COUNTY PERUT SERVICES ACCEPTED BY: HMDEI' E #: Z DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: Amount Paid15 , Payment DateLt gm Cr Payment Type Invoice # Check # Al3 Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003