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DocuSign Envelope ID:C744EDE1-7724-4AO7-B586-9488226B407F <br /> PIAN JOAQUIN I..UUX1'V ENV RONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store <br /> OWNER/OPERATOR <br /> Mark Tekin, TA Wilson Way, LLC <br /> CHECK ifBILLlNGADDRESS❑ <br /> FACILITY NAME <br /> 7-11 <br /> SITE ADDRESS 10 N Wilson Way Stockton 95205 <br /> Street Number Direction Street Name city Zin 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 Err. APN# LAND UsE APPLICATION# <br /> ( 469 ) 458-0485 1153-040-170-000 20NVVilson Way <br /> 153-040-260-000 10 N Wilson Way <br /> PHONE#2 Err. BOS DISTRICT--7LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Stephanie Fujimura CHECK ifBILLING ADDRESS <br /> ❑ <br /> BUSINESS NAME Dahlin Architecture Planning PHONE# ExT. <br /> ) 251-7288 <br /> HOME or MAILING ADDRESS 5865 Owens Drive FAx# <br /> CITY Pleasanton STATE CA ZiP 94588 <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,STATpawaamwagiv,laws. <br /> APPLICANT'S SIGNATURE: X i--1 DATE: 1/6/2020 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If-4PPL7cANT is not the Bi=NGP,4RTY 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 CT(41 <br /> COMMENTS: <br /> 0 <br /> ,��Nu.,yCo°�o <br /> �cryoEpARNr <br /> ACCEPTED BY: 6�1 F-1 / EMPLOYEE#: DATE: •J� T <br /> ASSIGNED TO: .�✓� EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s z P i E: <br /> Fee Amount: !_'--- Amount Paid SPayment Date <br /> Payment Type IqP Invoice# Check# �Ulo Recely d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />