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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 Fueling Station FA0007458 <br /> OWNER / OPERATOR <br /> 7- Eleven , Inc , CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME 7- Eleven Site # 32190 <br /> SITE ADDRESS 4943 S HWY 99 Stockton 95215 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O . BOX 711 ATTN : GASOLINE COMPLIANCE , LOC 148 Street Number street Name <br /> CITY Dallas STATE TX ZIP <br /> 75221 -0711 <br /> MENEEMENE <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 800 ) 828-0711 17931001 <br /> PHONE #2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) gm-envcompliancewest@7-11 .com 4 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Dale Adams CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT, <br /> Wilkey's Construction , Inc . 530 741 -2233 <br /> HOME or MAILING ADDRESS FAX # <br /> 4557 Skyway Dr. ( 530 ) 741 -2299 <br /> CITY Olivehurst STATE CA ZIP 95961 EMAadmin Wilke sconstruction . com <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 activity <br /> will be billed to me or my business as identified on this form . <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 <br /> COUNTY Ordinance Codes, StandaTATE and FED AL laws . <br /> APPLICANT ' SSIGNATUR � lla� DATE : J <br /> PROPERTY / BUSINESS OWNER ❑ ` OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Supervisor <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 site <br /> address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me or my <br /> representative . bA <br /> EMENEORPE <br /> TYPE OF SERVICE REQUESTED : l,/t S� �Mfi + R M <br /> COMMENTS: VFo <br /> sqN SFP <br /> 44 RO M� COO <br /> �FPgRN ,, TY <br /> ACCEPTED BY: . \ ' \ p rj) EMPLOYEE # : DATES SIC <br /> 9/249 / 2, <br /> ASSIGNED TO: v Vvr�l v`-- EMPLOYEE # : DATE : � 2k <br /> D I <br /> Date Service Completed (if already completed) : _ SERVICE CODE : <br /> - 2G PIE: 230 � <br /> Fee Amount: C�''� CT Amount Paid �O b. Ud Payment Date � ` 23 <br /> Payment Type Ll v� ��J Invoice # Check # 3H77 /C, 77974TV Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 03/22/23 <br />