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INSTALL_2022
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2300 - Underground Storage Tank Program
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INSTALL_2022
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Entry Properties
Last modified
1/23/2023 11:37:08 AM
Creation date
9/6/2022 3:22:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
INSTALL
FileName_PostFix
2022
RECORD_ID
PR0547873
PE
2361
FACILITY_ID
FA0000794
FACILITY_NAME
7-ELEVEN INC # 41530
STREET_NUMBER
1110
Direction
N
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
APN
21821023
CURRENT_STATUS
03
SITE_LOCATION
1110 N MAIN ST
P_LOCATION
04
P_DISTRICT
003
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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1N,�w36)a'48NC�1nN3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ti2�ti SERVICE REQUEST <br /> , ty FACILITY ID # SERVICE REQUEST # <br /> rwb <br /> merciak C - Store & Fuel Station SR0083066 <br /> I <br /> OWNER / OPER�TOR I <br /> 7- CleVen Inc . CHECK If BILLING ADDRESS <br /> FACILITY NAME #41530 7 - Eleven <br /> SITE ADDRESS 1110 N Main St . Manteca 95336 <br /> Street Number Direction I Street Name City 7112 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 0711 Street Number Street Name <br /> clrY Dallas STATE TX ZIP 95211 - 711 , <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # j <br /> (818) 201 4916 218 -210 -23 N /A <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 530) 925 4458 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Michelle Feasby on behalf of 7 - Eleven Inc . CHECK If BILLINGADDRESs ❑ <br /> Exr, <br /> BUSINESS NAME 7 - Eleven Inc . P 01 4916 <br /> HOME or MAILING ADDRESS PO Box 0711 FAX # <br /> ( ) <br /> CITY Dallas STATE TX ZIP 95211 - 711 <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 /> l <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 f! <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws , j <br /> APPLICANT' S SIGNATURE : Michelle Feasby eas3j'; ,ti ° , �."T ` " � " DATE • 2/ 15/2022 <br /> OrA 10:JMnT <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER E] OTHER OTHER AUTHORIZED AGENT ® Project Manager 1 <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Title I <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above l <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 . f <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS , General Contractor information : Wilkey's Construction IndNote : Tank installation currently f <br /> 4557 Sky Way Dr, Olivehurst , CA 95961 Contact : Mark scheduled for 2/25/2022WO LAId like to <br /> i <br /> Wilkey - Phone - 530 741 2233 & Dale Adams - Phone - request inspector for that date . <br /> 530 210 4111 I <br /> I <br /> I <br /> ACCEPTED BY: EMPLOYEE # : DATE : i <br /> I <br /> ASSIGNED TO : EMPLOYEE M DATE : <br /> 4 <br /> Date Service Completed (if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> l <br /> i <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />
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