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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ( SERVICE REQUEST # <br /> Gas Dispensing Facility +5 G <br /> OWNER / OPERATOR 7- Eleven , Inc CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> 7- Eleven #41531 <br /> SITE ADDRESS N Tracy Blvd . Tracy 95376 <br /> 3379 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 0711 Attn : Gasoline Compliance Street Number street Name <br /> CITY Dallas TX STATE ZIP 75221 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 916 ) 742- 0232 214 - 180 -210 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> HOME or MAILING ADDRESS FAX # <br /> CITY STATE ZIP <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 /> 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 : <br /> PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> t0 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 . <br /> TYPE OF SERVICE REQUESTED : S �' a4 / D RR 1k7` <br /> (� T <br /> COMMENTS : / Q <br /> Review fuel design plans for installation of (1 ) 10' dia. 20K gal. UST for diesel fuel, ( 1 ) 10' dia. 20K gal. UST for regular unleaded fuel , (1 ) 10' dia. 20K gal. split UST for 12K gal. diesI <br /> 8 ?0 <br /> SAN JO <br /> NFgCTH "I <br /> AQ AENT L TY <br /> RIME T <br /> ACCEPTED BY: /: � �� EMPLOYEE # : DATE: 1 <br /> ASSIGNED TO : Caro <br /> r ) Pre S f�o EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed ) : -- SERVICE CODE : 0 � ( f � ' PIE : 2 Of) <br /> Fee Amount: Amount Pai ; Payment Date4? 0go f 2 <br /> Payment Type - Invoice # Check # <br /> 1 / 27 b Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />