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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQi:FST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Detail Fuel ©�ax_51-7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS' <br /> FACILITY NAME 7-Eleven #2369-14117 <br /> SITE ADDRESS 2725 Country Club Lane Stockton 95201 <br /> Street Number Direction Street Name Citj I Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Numher Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( } 11 r <br /> CONTRACTOR t SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan - Compliance Manager CHECK ifBILUNGADDRESS <br /> ❑ <br /> BUSINESS MARE Walton Engineering, Inc . PHONE# Exr. <br /> 91§ 373 -1166 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O . Box 1025 191§ 373-1173 <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 <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: _ DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ff Compliance Manager <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERVICE REQUESTED. SIT IV6- ( e <br /> COMMENTS: <br /> a x Zoo <br /> ENVIROMIENTHEALT,y <br /> PER MI TISERVI cE, <br /> ACCEPTED BY: © L-I'J E-( 9A EMPLOYEE#: ?� / DATE: 3 Z S I X3 <br /> ASSIGNED T4: Y o/l) Fi-u F— EMPLOYEE#: V3 i-7 DATE: 3 <br /> Date Service Completed (if already completed): �� SERVICE CODE: 1 c� / P/E:Z3Q�a <br /> Fee Amount: 3+,r-7 �,� Amou Paid 3 JA 5 Payment Date 3 Sf <br /> Payment Type l� Invoice# Check# ,� S O Received By: �YG <br /> EHD 48-02-425 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />