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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Commercial - Convenience Store & Fuel Station IS � CID Colo J' <br /> OWNER / OPERATOR �J V <br /> 7- Eleven INC . CHECK if BILLING ADDRESS ® <br /> FACILITY NAME <br /> 7- Eleven <br /> SITE ADDRESS <br /> 1110 Street Number DN(rect(o� Main St . " Street Name Manteca 95336 <br /> Cit Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) Trade Center Dr. <br /> 11280 <br /> �— Street Number Street Name <br /> CITY Rancho Cordova STATE Zip <br /> CA 95742 <br /> PHONE #1 u ExT APN # LAND USE APPLICATION # <br /> ( 916 ) 742 0232 218-210-23 TBD <br /> PHONE #2 L ExT . BOS DISTRICT -I[ LOCATION CODE <br /> ( 530) 925 4458 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Crystal Justice CHECK it BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # ExT. <br /> 7- Eleven 916 742 0232 <br /> HOME or MAILING ADDRESS 11280 Trade Center Dr. FAX # <br /> CITY Rancho Cordova STATE CA Zip 95742 <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, STAd <br /> T nDERAL lar -- <br /> 11 <br /> APPLICANT' S SIGNATURE : _ DATE : LA ( (7UO) <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER IXI OTHER AUTHORIZED AGENT D _ <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 isIV rr <br /> my representative . / Ca IV <br /> TYPE OF SERVICE REQUESTED: T S <br /> Vt <br /> COMMFNTS: UL C <br /> 2 9 2020 <br /> SAN JOAQUIN COU Ty <br /> HEALTH DEP ENTAL <br /> ARTME T <br /> ACCEPTED BY: -77 CM <br /> EMPLOYEE # : DATE ; <br /> ASSIGNED TO : S ' �J EMPLOYEE #: DATE ; / 4 <br /> Date Service Completed ( if already Completed ) : SERVICE CODE : C / / PIE: �� <br /> Fee Amount: � Q ;c Amount Pa ' 3 Payment Dater <br /> Payment Type Invoice # Check # 11722. 6 1 Recei d By : - <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />