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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility —7J S�-OC y7 35 -3--7 <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS El <br /> FACILITY NAME 7-Eleven #32190 <br /> SITEADDRESS 4943 South State Route 99 Stockton 95206 <br /> Street Number Direction I Street Nameci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Exr. AP N# LAND USE APPLICATION# <br /> It ) j'7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( } 0(> 1 G1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK if BILLINGADDRESS'L <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME or MAILING ADDRESS P.O. Box 1025 (9AX 16) 373-1172 <br /> CITY West Sacramento STATE CA Z'P 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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE an EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 <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 soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: CC <br /> GX� I � <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: `T�ff `�„ I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERMCE CODE: 9W PIE: a <br /> Fee Amount: to Amount Pai Lv/ OD Payment Date g <br /> Payment Type e Invoice# Check# L3- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />