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05/04/2009 13:17 9163731173 WALTONENGINEERING PAGE 09 <br />SAN JOAQU*OUNTY ENVIRONMENTAL HEALTWEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rv-n-am <br />FACILITY ID 0 SERVICE REQUEST # <br />Retail Fuel <br />Wt:COMMENTS: 111:1u ILD <br />MAY 0 4 2009 <br />SAN JOAQ mr%i Gal 1pl:p. <br />373-1166 Err. <br />OWNER I OPERATOR <br />FAX 0 <br />(916) <br />7 -Eleven, Inc. <br />CHECK if <br />FACILITY NAME <br />zip 9569 <br />7 -Eleven #32262 <br />SITE ADDRESS 2360 <br />TA <br />Grantline <br />Road <br />Tracy <br />95377 <br />What NgmLsi-A <br />Invoice # <br />I <br />Stmat Name <br />By: <br />f <br />CIN21 <br />Cotle <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Etre <br />41n�r <br />CITY <br />STATE zip <br />PHONE #1 EXT, APN4 <br />LAND USE APPLICATION 4 <br />PHONE #2 <br />803 DISTRICT LocA-noN CODE <br />CONTRACTOR / SERVICEREQUESTOR <br />REQUESTOR Dulcinea Webb <br />rv-n-am <br />CHECK if L3JWN-G-ADD1tES8 <br />BUSINESS NAMEWalton Engineering, INc. <br />Wt:COMMENTS: 111:1u ILD <br />MAY 0 4 2009 <br />SAN JOAQ mr%i Gal 1pl:p. <br />373-1166 Err. <br />HOME or MAILING ADDRESS <br />P.O. BOX 1025 <br />FAX 0 <br />(916) <br />3731172 <br />Crry West Sacramento <br />STATE CA <br />zip 9569 <br />BRIM <br />G AE1QjqffiaJEDGE N=: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project s.pecific ENvTRONmENTAL.HEALTFI DEPART wFNT hourly charges associated with this project <br />or activity will be billed to me or my business as Wentijl5ed 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- DATE: <br />PROPERTY / BUSINESS OWNERE3 OPERATOR/ MANAGER ❑ OTmR AuTHopjzw AGENT CY Compliance Manager <br />1fAPPmcANTisnot the BH,LwGPAR i proof of authorization to sign is required r: rte <br />AUTUMZATIGN TO Uj&&IE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />. <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 som as it is available and at the game time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED.' <br />rv-n-am <br />Wt:COMMENTS: 111:1u ILD <br />MAY 0 4 2009 <br />SAN JOAQ mr%i Gal 1pl:p. <br />AccEPTiED BY: <br />EmpLoyam 0: ENViRON MNAL —, <br />HEA mr, <br />ASSIGNED TO* <br />EmpLoyise <br />Date Service Completed (if already comp)eftd), <br />SERVICE CODE: <br />_7Payment <br />PIE: <br />Fee Amount. Amount Paid <br />Date <br />-i0-ceIved <br />Payment Type <br />Invoice # <br />I <br />Check a <br />By: <br />f <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />