Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Commercial - Convenience Store & Fuel Station <br />FACILITY ID # I <br /> <br />A' r-1 2' ' fr h Wpwfi v r' wi <br />SERVICE REQUEST # <br />S 0 0g3C0 2- OWNER/OPERATOR <br />7-Eleven INC. CHECK if BILLING ADDRESS <br />FACILITY NAME <br />7-Eleven <br />SITE ADDRESS <br />1 1 10 N. <br />Street Number Direction Main St . Street Name Manteca <br />City 95336 <br />Zip Code HOME or MAILING ADDRESS (If Different from Site Address) <br />11280 <br />Street Number <br />Trade Center Dr. <br />Street Name CITY Rancho Cordova STATE ZIP <br /> CA 95742 <br />PHONE #1 EXT. <br />( 916)742 0232 <br />APN # <br />218-210-23 <br />LAND USE APPLICATION # <br />TBD <br />PHONE #2 EXT. <br />( 530)925 4458 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE <br />REQUESTOR <br />Crystal Justice <br />... <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 7-Eleven PHONE # <br />(916)742 0232 <br />Ext. <br />HOME Or MAILING ADDRESS <br />11280 Trade Center Dr. FAx # <br />( 1 <br />Cri-y 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, STAT nd DERAL Ial <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 10 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required <br />0“ Of) <br />Title <br />DATE: <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 aRe.ssment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tim:W4glowittsi;o me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: N.( (4) p (ct.1.-- c Le_c k__ * L'e el VED <br />COMMENTS: OEC <br />skvJoAQu <br />i <br />l <br />4 2020 <br />14 EIVVIROIV NC°U1VTY —EALT11DepALENTAL <br />'IrwrlifEiv r <br />ACCEPTED BY: Ca.Af-,c,,t, Cs c_cy EMPLOYEE #: DATE: / 2_--/ 0— ")-e7 <br />ASSIGNED TO: R4 Pvel/l. ti EMPLOYEE #: DATE: ( 2_--( 0 —7.-0 <br />Date Service Completed (if already completed): SERVICE CODE: s"--2._.-3 P /E: 16 0 0 / <br />Fee Amount: Amount Paid 4 Lisle , Payment Date I 2_1 11+ I 24 <br />Payment Type i Invoice # Check # i 1 1 2,21 Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)