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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Dispensing Facility 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 TX STATE ZIP 75221 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 916 ) 742-0232 214- 180-210 PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Michelle Feasby CHECK if BILLINGADDRESSE] BUSINESS NAME TAIT & Associate on behalf of 7- Eleven PHONE # T 916 669 1836 HOME or MAILING ADDRESS 11280 Trade Center Dr. FAx # CITY Rancho Cordova CA 95742 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, TE and FEDERA ws. AP,Pi,tCA(VT'S.k IONATURE :;> DATE : I Q PROPERTY / BUSINESS OWNER P9 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT i5 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 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 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: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Recelved By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08