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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Q 00gq 0 l lQ <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Vixxo <br /> FACILITY NAME <br /> 7- Eleven #41216 <br /> SITE ADDRESS <br /> 760 ! � � W Charter Way Stockton 95206 <br /> Street Number Direction Street 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 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> Veronica Freitas <br /> BUSINESS NAME PHONE # ExT, <br /> Walton Engineering , Inc . 916 373-1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 , West Sacramento, CA 95691 ( 916 ) 373-1171 <br /> CITY STATE CA ZIP 95691 <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 or <br /> activity will be billed to me or my business as identified on this form , <br /> 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 : DATE : \ luj a <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 Contractor <br /> If APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me or <br /> my representative . RP <br /> TYPE OF SERVICE REQUESTED : ( � V T IZI / U� ` � `, <br /> COMMENTS : IZIJ <br /> Dr�1 <br /> SAN 10A X02' <br /> HEALTH p PAR HNTY <br /> MENT <br /> ACCEPTED BY : C 1 !n rj� EMPLOYEE # : DATE : <br /> ASSIGNED TO : /t va44 � e let EMPLOYEE # : DATE : 1411 <br /> Date Service Completed (if already completed) : / ✓3 �J / SERVICE CODE : / /) (f �Gf� PIE : Zr3�� <br /> Fee Amount : ti�" �— � 00 Amount Pal H �, OD Payment Date / <br /> Payment Type Invoice # Check # S� By : <br /> $�� Receive <br /> EHD 48 -02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />