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DocuSign Envelope ID:C744E I14U2nAINJUAQUN V1VBh N VtRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store <br /> OWNER I OPERATOR <br /> h <br /> Mark Tekin, TA Wilson Way, LLC CHECK if BILLING ADDRH55 <br /> FACILITY NAME <br /> 7-11 <br /> SITE ADDRESS 10 N Wilson Way Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2600 N. Dallas Parkway, Ste. #370 <br /> Street Number Street Name <br /> CITY Frisco STATE ZIP <br /> TX 75034 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 469 ) 458-0485 1153-040-170-000 26 N Wilson V <br /> 153-040-260-000 10 N Wilson Way <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Stephanie Fujimura CHECK If BILLING ADDRESS <br /> BUSINESS NAME Dahlin Architecture Planning PHONE# ExT. <br /> ( 925 ) 251-7288 <br /> HOME or MAILING ADDRESS 5865 Owens Drive FAx# <br /> ( 1 <br /> CITY Pleasanton STATE CA ZIP 94588 <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 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 1 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, STAT7,7�4 <br /> n laws. <br /> APPLICANT'S SIGNATURE: V—� DATE: 1/6/2020 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT❑ <br /> If APPLICANT is not the B1LLIAFG PARTy,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: Environmental Health Plan Review f F �-p-e-{Y � <br /> COMMENTS: <br /> -14 <br /> %'J0 ?010 <br /> H D COI J Y <br /> /� <br /> ACCEPTEnBY: / prr� EMPLOYEE#: DATE: J� r <br /> O <br /> ASSIGNED TO: '.��� d EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P I E: <br /> Fee Amount: Amount Paid zv)��. Payment Date �p <br /> Payment Type /7P Invoice# Check# S Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 fit'+ <br />