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SAN JOAQU�COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station --2,� _f:�K bC)T2-61 <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 7-Eleven #32262 <br /> SITE ADDRESS 2360 W Grant Line Rd. Tracy 95377 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number F Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ) <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering,Inc. (916)373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 1916 373-1171 <br /> CITY West Sacramento STATE CA ZIP 95620 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: 07/29/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor <br /> If APPLICANT is not the BILLING PARTY,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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative. pqr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3 <br /> Q'T <br /> ACCEPTED BY: EMPLOYEE#: DATE: I� <br /> ASSIGNED TO: f2hL� C EMPLOYEE#: DATE: ;17t� <br /> Date Service Completed (if already completed): t/ SERVICE CODE: PIE: <br /> Fee Amount: ?j��•_� Amount Pai i...0 D Payment Date 7 �� <br /> Payment Type Invoice# Check# �17 TMJ Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />