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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property DODO <br /> ID SERVICE REQUEST# <br /> Existing 7-Eleven DODO S�6071�q <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK If BILLING ADDRESS 10 <br /> FACILITY NAME <br /> 7-Eleven <br /> SITE ADDRESS 1048 1/y Yosemite Manteca 95337 <br /> Street Number I DimetionStreet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ET APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mia Rondone CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> Permit Place 661 857 5620 <br /> HOME or MAILING ADDRESS FAX# <br /> 13400 Riverside Dr#202 ( 1 <br /> CITY Sherman Oaks STATE CA ZIP 91423 <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, an EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/06/20 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® Permit Expediter <br /> If�APPL/CANT is not the BILL/NG 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 t!nC,a�roeAt}pte It Is <br /> provided to me or my representative. R r 't I.Ov <br /> TYPE OF SERVICE REQUESTED: Plan CheckF <br /> nn- <br /> COMMENTS: 0 DvIve SA LI 3 'lo <br /> It N JOA <br /> Equipment change for existing 7-Eleven. y-'ALN <br /> A T H D PARTMt NT <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEEM 6213 DATE: 10-13-20 <br /> ASSIGNED TO: CTehane Pahmy EMPLOYEE#: 8788 DATE: 10-13-20 <br /> Date Service Completed (If already completed): SERVICE CODE: 523 P i El.1601 <br /> Fee Amount: 456 Amount Pa �Da Payment Date ZD <br /> Payment Type Invoice# Check# /,Sr3�S-22� ecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />