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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Properly FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # Existing 7 Eleven O�% 3 7 Etr. 857-5620 SQ O oo OWNER/ OPERATOR FAX# camf`bs� ferry'" ac -tet 7 Eleven Inc. STATE CA CHECKIf BILLINGADDREsS FACILITY NAME 7 Eleven DATE: SITE ADDRESS 7647 I Pacific Ave DATE: Stockton 9 527 Street Number Direction Fee Amount: Street Name Amount Paid D Ci HOME or MAILING ADDRESS (if Different from Site Address) Invoice # I C C`/ Rece' Street Number CITY STATE zipA///a O V .7 9nes PHONE #1 Ex . APN # LAND USE APPLICATION # ✓OqV ( 1 hFgE� V/Roty /N COQ PHONE #2 Ext ( 1 BOS DISTRICT LOCATIO SME CONTRACTOR / SERVICE REQUESTOR REQUESTOR MIA Rondone CHECK If BILLING ADDRESS BUSINESS NAME Permit Place PHONE # 661 Etr. 857-5620 HOME or MAILING ADDRESS 13400 Riverside Dr. #202 FAX# camf`bs� ferry'" ac -tet CITY Sherman Oaks STATE CA ZIP91423 ur ,0 ry BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL. HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FED S. APPLICANT'S SIGNATURE: DATE: DATE: 7/26/2021 PROPERTY/BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZEDAGENT N Authorized Agent If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. < TCA S rrl.tel TYPE OF SERVICE REQUESTED: Plan Check ' rod r i u e t COMMENTS: Install(2) Cabinets for Hot dog rollers & a new self serve sneeze guard converting from employee serve to self serve. ( ) camf`bs� ferry'" ac -tet porn ACCEPTED BY: Cu V"f yL.-',S co EMPLOYEE M DATE: 7-2-9--Y ASSIGNEDTO: kY (_ EMPLOYEE#: DATE: 7-2s4-7-4 Date Service Completed (If already Completed): SERVICE CODE: I^Z71 P 1 E: ' &o Fee Amount: — Amount Paid D Payment Date Payment Type I Invoice # Check # Z 2-7 Rece' ed By: IJA— EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 :-Oryll