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Chr�e of a�,r.�.n <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1Z1612v <br /> SERVICE REQUEST <br /> Type of Business or Property I FACILITY ID# SERVICE REQUEST# <br /> Convenience Market wfa 5 V-6v <br /> OWNER I OPERATOR', r— <br /> SCHECK If 1311-UNG ADDRESS❑O' S <br /> (FACIUTY NAME, <br /> 7-Eleven 17647D <br /> SITE ADDRESS 1048 W Yosemite Ave Manteca 95337 <br /> Street NYmbe1 I DLecOen St Neme cityL o <br /> ,HOME or MAILING ADDRESS,(If Different from Site Address) <br /> 8255 Medeiros Way,Sacramento CA 95829 St.el Nembm <br /> CITYSTATE zip <br /> �HW39-2329 ER APN# LAND USE APPLICATION# <br /> PHONE 02. BOS DISTRICT LOCATON CODE <br /> 916-917-7201 <br /> 71 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> (REQUESTOR' G.Urbeer Somal CHECK If BILLING ADDRESS® <br /> (BUSINESS NAME PNONE# ' <br /> Somal&Sons Inc. <br /> ,Home or MAILING ADDRESS' FAX# <br /> P.O.-Box 219088,-Dallas, TX 75221 ( i <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALT-H DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 Codec,Standards,STATE a#FEDERAL laws., <br /> APPLICANT'S SIGNATURE_: wtr+2P� JoM a! DATE 11 / 1712020 <br /> PROPERTY/BUSINFSS0w'NF,R01 OPERATOR/MANAGER ❑ OTHER AtmIORIZED AGENT❑ <br /> 1fAPPLic4NT is not the BILLING PART)'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 I-IFALTH DEPARTMENT as soon as it is available and at time it is <br /> provided to me or my representative. ^^1I/M <br /> TYPE OF SERVICE REQUESTED: -%�lt/V46 <br /> COMMENTS: Mull <br /> tsgN�aq <br /> t H�E�N lqpotv /V CO M6 �Nl <br /> ACCEPTED BY: EMPLOYEE#: CIO <br /> DATE: 11 I ;V <br /> ASSIGNEDTO: EMPLOYEE#: DATE: I 11QAv <br /> Date Service Completed (If already completed): SERVICE CODE: OU I PIE: <br /> Fee Amount: Amount . Payment Date # <br /> Payment Type Invoice# Check# elv By: <br /> EHD 46-02-025 Please.-call Cathy Myers SR FORM(Golden Rod) <br /> REVISED 11/17/2003 916-730-6825 or entail <br /> Doc to:f0a7B6bed377fOb93465969becea31hd37f44205 <br /> Cathy@.ccgweSLCOM with questions M(v 1 <br /> �3Z <br />