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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nSERVICE REQUEST# <br /> Convenience Store STORE NO. 1042991 7lf- 00$2 S 5 <br /> OWNER I OPERATOR <br /> Beverly Group LLC CNECKN BILLING ADDRESS❑ <br /> FAOLRY NAME 7-Eleven Stare <br /> SrTE ADDRESS 613CAROLYN WESTON BLVD. STOCKTON <br /> at'.. <br /> ft W, 1 01.11. n,.. <br /> zip aea <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 040 Macarthur BI <br /> CITY Newport Beach STATE CA zm 92660 <br /> PHONE#i En. APN# LAND USE APPUCAnON# <br /> (949) 566.8164 16422016-16422019 <br /> Pinw#2 Eer. 805 DISTRCT LoCAnoN Done <br /> 1 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> Bong Adao CHEcN II Biww ADDRESS❑ <br /> BUSINESSNAME MCkently Malak Architects pbLb 583.8348 <br /> X <br /> HoMEor MAtunGADDRESS 35Hugus Alley#200 FAT# <br /> ( ) <br /> CITY Pasadena STATE CA Zip 91101 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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: A% DATE: 06.262020 <br /> PROPERTY/BUSINESS OIYNER❑ OPERA OR//+MANAGER ❑ OTIIER AUTHORIZED AGENT® <br /> 1fAPPLICAAT is not the BILUNG PARTI,'.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information IO the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same Ai <br /> provided to me or my representative. 'l PA <br /> TYPE OF SERVICE REQUESTED: <br /> CDIreE"1s: Environmental Health Plan Check review for a 3,062 SF : 7-11 Build to Suit. Sq ( 08 <br /> Na <br /> OQ <br /> ACCEPTEDBY: EMPLOYEE#: DATE: _-Z ) ENT'l <br /> ASSIGNED TO: L 1, EMPLOYEE#: DATE: <br /> Date Service Completed IN already completed): SERVICE CODE: C? J IPIE: j V u ' <br /> Fee Amount: * 0 Amount Pav �- CO Payment Date ? 2(� <br /> Payment Type .51-i Invoice# Cheek# 'I Ob 2-5-- Ricalved By: <br /> EHD 48.02-M SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />