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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business a Property F!A'�CILITY ID# � / SERVICE REQUEST# <br /> Convenience Storer 7 Eleven ��✓V�1TS sP—d 0�tpZf „I <br /> OWNER I OPERATOR t� <br /> 7 Eleven Inc. CHECK If BIW NGADDRE$$❑ <br /> FACILITY NAME <br /> 7 Eleven 17334H <br /> SITE ADDRESS <br /> 4501 N 5b 114umber Direction Pershing Av% ..<x me Stockton 952I city 0 . <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO BOX 139044 <br /> Sb.a Number <br /> Cm Dallas STATE TX ZIP 75313 <br /> PHONE#1 Ec. APN# LAND USE APPLICATION# <br /> t 1209-951-6745 <br /> PHONE#2 E%r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 7 Eleven Inc. CHECKIf MLLINGADORE53❑ <br /> BUSINESS NAME PHONE# Exr. <br /> 7 Eleven 17334 <br /> HOME or MAILING ADDRESS PO BOX 139044 FAx# <br /> ( 1 <br /> CITY Dallas STATE TX ZIP 75313 <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 /> 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �/J i lI" DATE: 01 /13/2023 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Agent, 7 Eleven Inc. <br /> /f APPLICANT is not the BILLINGPAR77 prdofof authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,the owner or operator of the pr erty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environrr�ll�Rl essment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl¢ar�q[[{w, t�t�e�t i3 <br /> provided to me or my representative. ��l(.�. �V <br /> PO <br /> TYPE OF SERVICE REQUESTED: 01? A <br /> COMMDM: SAN SOA <br /> Change of ownership inspection E QUI <br /> HEgLTH p p REw <br /> TM L Ty <br /> ACCEPTED BY: L I EMPLOYEE#: 4O('7•� DATE: I 1 <br /> 7 <br /> ASSIGNED TO: EMPLOYEE#: /7YV� DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: OT PIE: �— <br /> Fee Amount: $1 E(p Amount Paid $15(o Payment Date / `-71,-)-2>- <br /> Payment <br /> 7a2>Payment Type MAST /Invoice# Check# I720 Received By: <br /> EHB 4802.025 Cor ryy/ rpmk,; tt�`J /J `�7--4-00 Y <br /> REVISED 11/1712003 SR FORM(Golden Rod) <br /> Doc ID:eO9d542703447120ab5af4a8b65f3409d65ba555 <br />