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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # � ERVICE REQUEST # <br /> Gas Station o 00 0 (1Lv <br /> OWNER / OPERATOR CHECK if BILLING ADDRESSO <br /> Vixxo <br /> FACILITY NAME <br /> 7-Eleven #41187 <br /> SITE ADDRESS <br /> 1829 N. Wilson Way. Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7000 E. Shea Blvd . Ste H1970 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Scottsdale AZ 85254 <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <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 ( ) <br /> CITY West Sacramento 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, STT and EEDERA ave <br /> APPLICANT'S SIGNATURE : ,t ;'I . - DATE : 11 /4/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® 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 . P <br /> TYPE OF SERVICE REQUESTED : - RFT <br /> COMMENTS : �J„ N / 2� �j' �! N0 U <br /> yc( O� sA 2022 <br /> N JO <br /> HEq�ry L)Pq��,NTy <br /> // TMENT <br /> ACCEPTED BY : \ EMPLOYEE # : DATE : I 2 `- <br /> � V <br /> ASSIGNED TO : 5::� 10 I EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : Z Z SERVICE CODE lqil yG c� PIE: <br /> 2c <br /> Fee Amount Lf fr r / Amount Paid 936 . Payment Date �� Z <br /> Payment Type CL Invoice # Check # (o (� 1 Received By: <br /> FkJ I L4tre -fo o JC)r (�a4 " C� � Is z B7 g?e,,7 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 / pen <br />