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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Dispensing Facility #41531 OWNER / OPERATOR 7 - Eleven , Inc CHECK If BILLING ADDRESS ® FACILITY NAME 7-Eleven #41531 SITE ADDRESS N Tracy Blvd . Tracy 95376 3379 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) P . O . Box 0711 Attn : Gasoline Compliance Street Number Street Name CITY Dallas STATE TX ZIP 75221 PHONE #1 Ex-r. F21 N # LAND USE APPLICATION # ( 916 ) 742-0232 4 - 180 -210 PHONE #2 ExT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE # ExT. HOME or MAILING ADDRESS FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized 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 FEDERAL laws . APPLICANT' S SIGNATURE : DATE : PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER 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 . TYPE OF SERVICE REQUESTED : COMMENTS: 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. diesel fuel ACCEPTED BY : EMPLOYEE #: DATE: ASSIGNED TO : EMPLOYEE #: DATE : Date Service Completed ( if already Completed ) : SERVICE CODE : PIE : Fee Amount : Amount Paid Payment Date Payment Type Invoice # Check # Received By : EHD 48-02-025 SR FORM (Golden Rod) 07/17/08