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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SFRVICF REQUEST # <br /> Gas Station F 64 0001 EV 7 U 00 t461 �- <br /> OWNER / OPERATOR <br /> VIxxQ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven # 35355 <br /> SITE ADDRESS 3202 W Hammer Lane Stockton 95209 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering , Inc PHONE # Exr• <br /> ( 916- ) 373- 1166 <br /> HOME or MAILING ADDRESS P . O . Box 1025 FAx # <br /> CITY West Sacramento STATE CA ZIP 95691 <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 /> 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 : b6 (§00 <br /> DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT m Contractor <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 <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 . 11 <br /> TYPE OF SERVICE REQUESTED : s Pr R e .f77 <br /> COMMENTS: <br /> n <br /> L N <br /> ACCEPTED BY : , (� tv C R � v e �r EMPLOYEE # : DATE: <br /> ASSIGNED TO : V L,, Q('iv Put� Ll /D�J,yre da EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : 2 q12 5 SERVICE CODE : f� 6 261 P 1 E:23 (�8 <br /> Fee Amount : ykf f 969 �� Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> ----� •moi I Loa, tv dafm n ogto Lit <br /> EHD 48-02-025 0 % SR FORM (Golden Rod) <br /> 07/17/08 � 1�1 A� � � ��y <br />