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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Station 12-5 <br /> OWNER/OPERATOR (N <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 7-Eleven Inc#38616 <br /> SITE ADDRESS NW Corner of Carolyn Weston Blvd.&Manthey Rd. Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 711:Attn:Gasoline Department <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dallas TX 75221 <br /> PHONE 91 EXT. APN# LAND USE APPLICATION# <br /> (972 ) 828-7930 <br /> PHONE#2 EXT. BOS DISTRICTLOCATI N CODE <br /> (916 ) 340-4182 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Robert Forloine-Project Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PM Design Group, Inc. PHONE# EXT. <br /> 707)387-9883 <br /> HOME or MAILING ADDRESS 3860 Broadway Street, Suite 110 FAX# <br /> CITY American Canyon STATE CA ZIP 94503 <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: l�► Get-7 DATE: 08/27/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Manager <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. <br /> 1 A <br /> TYPE OF SERVICE REQUESTED: L'l - T S� �f7 W/V <br /> COMMENTS: EL) <br /> SAN OCT 15 2020 <br /> JOA <br /> HEA TH p�PMENNL ry <br /> ART <br /> ACCEPTED BY: S v EMPLOYEE M DATE: f1 <br /> ASSIGNED TO: tJ V EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:,�2 <br /> Fee Amount:- <br /> "0 Amount Paid304 D Payment Date I b I I <br /> Payment Type Invoice# Check# b Received By: SIJ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />