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' SAN JOAQUIN RUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY # <br />SERVICE REQUEST <br />OWNER/ OPERATOR <br />7 -Eleven Inc . <br />CHECK if BILLING ADDRESS ❑ <br />FAcILmNAME 7 -Eleven #2368-32262 <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />SITE ADDRESS 2360 <br />Street Number <br />W <br />Direction <br />Grant 1 ine Road <br />I Street Name <br />Tracy <br />city <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />ACCEPTED BY: <br />LAND USE APPLICATION # <br />PHONE R <br />( ) <br />EXT. <br />DATE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Webb <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />COMMENTS: U C/ <br />PHgq15 <br />373-1166 EXT. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />FAX # <br />(916)373-1172 <br />CITY West Sacramento <br />STATE CA <br />ZIP 95691 <br />BILLING ACKNOWLEDGEMENT: I, 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, and FEDERAL, laws. <br />APPLICANT'S SIGNATURE: DATE: a a� - 09 <br />PROPERTY/BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Manager <br />IfAPPLlcANT is not the BILLING PART): proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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/ ,assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the's ;t xlie it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: U C/ <br />J�F ON <br />ACCEPTED BY: <br />' ' l I I <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: b 270. <br />Amount Paid <br />3j 0 0 <br />Payment Date 3 <br />Payment Type <br />Invoice #I e-7333 <br />Check # Lt p r <br />±) <br />Received By: <br />EHD 48-02-025 keV/'o WS IL�V)A ` �' 2/qo 1 �:' CJ1-- V T D L EZ, LY' 3 / S. D!) SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />