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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST It <br /> Gas Dispensing Facility b A0 <br /> OWNER / OPERATOR <br /> 7-Eleven , Inc CHECK If BILLING ADORESSL <br /> FACILITY NAME 7-Eleven , Inc. '..,. <br /> SITE ADDRESS Stockton 95205 <br /> 10 Wilson Way <br /> 6lreet Number Direction Street Nome CftV Zip Cada <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2600 N , Dallas Parkway Ste 370 Street Number S(reet Name <br /> CITY STATE Z)P5034 <br /> Frisco TX 5 <br /> PHONE III Exr. APN fI LAND USE APPLICATION iI '.. <br /> (916 ) 742-0232 159-040-260 & 153-040-170 <br /> PHONEII2 EXT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Karly Zacher on behalf of 7-Eleven, Inc. CHEC/Cif BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT' <br /> Tait & Associates 916 669-1830 <br /> HOME or MAILING ADDRESS FAX It <br /> 11280 Trade Center Dr. ( ) <br /> CITY Rancho Cordova STATE CA ZIP , _957a <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or businesa� wnipr d eratOl or >aut60,tzed ;6gednt of same <br /> acknowledge that all Site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTM NTt i r"iy 'charges associated with this project or <br /> activity will be billed to one 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 do Win accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL IaWS. <br /> APPLICANT'S SIGNATURE! � j., ) , V { %� � illl { ` <br /> PROPERTY / BUSINESS OWNER CI OPERATOR / MA AGER ❑ OTHER AUTHORIZED AGENT JWVj�-f+GWDCf61 <br /> IfAPPucANT is not the BILLING PARTY. proof of authorization to sign is required Tifte <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same ting it is provided to ine or <br /> my representative. N ^Velf qo <br /> TYPE OF SERVICE REQUESTED: t`,/-..x� � � l tm <br /> COMMENTS: <br /> &&((ff8 <br /> Sq%JOA /7y 2®10 <br /> N4111Ty� COU <br /> ARTMFNT: <br /> ACCEPTED BY: -r EMPLOYEE II: DATE: f _- <br /> iSr f L f., f` ,�`` <br /> ASSIGNED TO: , fEMPLOYEE DATE: ICP ..t�} <br /> Date Service Completed (If already completed) : __w_._.....—. SERVICECODE; ; PIE: 23OZ3 <br /> Fee AmountAmount PaC�/, i. y jr Payment Date %1� / Y <br /> Payment Type Invoice # Cheek # Received By : /77 <br /> 1 / <br /> EHD 48-02.026 I " - � SR FORM (Golden Rod) <br /> 07/17/08 <br />