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❑ New Facility Existing Facility ►�eecEs s2 San Joaquin County Environmental Health Department Application Form Facility Name 7-Eleven #43208 Site Address City State CA ZIP 95204 2705 Country Club Blvd. Stockton APN Supervisor District 121- 4210 -0 Type of Service ❑ Application for ❑ Consultation ❑ Change of owner ® Repairs or Remodel ❑ Other Requested Operating Permit Comments Replaced diesel leak detector with like for like equipment. If mobile food truck or License Plate Number VIN pumper truck Contact Types 0 Billing Party ® Facility Owner ❑ Facility Contact ❑ Property Owner 0 Contractor ❑ Architect required Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect e0,C, �r First Name Last name If contr ,ctor, indicate type and license number Walton Engineering, Inc Address City State A P P.O. Box 1025 West Sacramento CA 95691 Phone Phone veronica.f walton n ineerin com 916-373-1166 @ g 9� ❑ Billing Party ❑ Facility Owner Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number 7-Eleven Address City State ZIP P.O. Box 711 Dallas TX 75221 Phone Phone Email ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNUQrdina�ENT APPLICANT'S SIGNATURE: Standards, STATE and DERAL layl�. a�D � 06/05/25 PAYMENT .� DATE: RECEIVED ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER 2 OTHER AUTHORIZED AGENT Contractor Title 'JUL" 17 2025 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site add Wedz*,, L release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVI NT TA DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Acce B A i ned ,o L ntM� Lin F I P v {��y �J y� oj2.g.� 60 20 qg Dates �� 5 PE2�08 e"�J T � RecorVNiiba 5 i a$ 1. �DWr �—y R� V�� Payment ❑ Cash ❑ Check# Confirmation# i pwn Received By Rev 07/10/2024 ' i::iu 1(ec"V TV D to �i_h {9eflul f afp L;