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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �SERVICE REQUEST# <br /> Convenience Store, 7 Eleven U <br /> OWNER/OPERATOR v <br /> Jagjeet Singh CHECK If BILLING ADDRESS <br /> FACILITY NAME 7 Eleven 20680C <br /> SITEADDRESS 9110 Thornton Rd. Stockton 95209 <br /> Street Number Direction Street Name CI Zip C.de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PO BOX 219088 <br /> Street Number Street Name <br /> CITY Dallas STATE TX ZIP 75221 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) 209-477-6701 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> ( ) 206-786-7087 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 7 Eleven Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAME 7 Eleven 206800 PHONE# 206-786-7087 Exr. <br /> HOME or MAILING ADDRESS PO BOX 219088 Fax# <br /> CITY Dallas STATE TX ZIP 75221 <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: ( DATE: 05/06/2021 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUT IORIEED AGENT❑ <br /> If APPLICANT is not the BILLiAGPARTY 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: ry y <br /> COMMENTS: <br /> Change of ownership inspection <br /> yE NSA�o FO0ON, <br /> p )- <br /> ACCEPTED BY: (A. EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: VS DATE: 'Wj, .y <br /> Date Service Completed (if already completed): SERVICE CODE: P <br /> Fee Amount: $152 Amount Paid $152 Payment Date 5/6/2021 <br /> Payment Type MAST I Invoice# Check# /2 90� Received By-MP <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �YZQ <br /> l9 Z Doc ID:de751402f4ca5b69108aab34855b63c7d0255d6a <br />