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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station � Z4 <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS D <br /> 7- Eleven , Inc . <br /> FACILITY NAME 7- Eleven #20632 <br /> SITE ADDRESS <br /> 4627DaVinci Dr Stockton 95207 <br /> Street Number Direction Street Name Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT [APN7# LAND USE APPLICATION # <br /> ( 714771 -5484 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> James Otto Contractor ( Project Coordinator) <br /> BUSINESS NAME PHONE # EXT. <br /> LC Services 559 444- 1730 <br /> HOME or MAILING ADDRESS FAX # <br /> 3887 N . Valentine Ave ( ) <br /> Ciro Fresno STATE CA ZIP 93722 <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, STATE and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : O4Z`— DATE : 2/28/2020 <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / MANAGER ❑ OTHER AUTHORizEDAGENTX Project Coordinator <br /> 1fAPPL1CANT 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 DEPARTm app as, lt-1 vallab)p ( #11e same time it is <br /> provided to me or my representative. r <br /> TYPE OF SERVICE REQUESTED : [ r) X T ? <br /> COMMENTS : f LI. ' 2 9 2019 <br /> ENVIRONMENTAL HEALTH <br /> LTH <br /> 1 �tTI�eMENT <br /> ACCEPTED BY: � -L-n /J J � EMPLOYEE #: DATE: C42 Q �O <br /> ASSIGNED TO : G� ( � n / o EMPLOYEE #: DATE: 021; pU <br /> Date Service Completed (if already completed) : — SERVICE CODE : 0 / 4 P 1 E : CA 30 <br /> Min <br /> Fee Amount: Z/ ✓ Amount Paid Payment✓Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 4&02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />