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SAN JOAQUII LINTY ENVIRONMENTAL.IIEALT*EPARTM NT <br /> SERVICE REQUEST ;; (1, <br /> Type of Business or Property <br /> FACILITY 10# SERVIC F'EQUEST# <br /> Retail Fuel <br /> OWNER! 0PERATOR CHECK if BILLING ADORESS❑ <br /> FACILITY NAME 7—Eleven #2369-14117 <br /> SITE ADDRESS <br /> 2725 Country Club Lane Stockton 9520 . <br /> Street Number Direction <br /> Street Name Cit Zi Code <br /> HOME or{MAILING ADDRESS (If Different from Site Address) <br /> Street-Nu mber Street Name <br /> STATE ZIP <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS <br /> Dulcinea Conan - Compliance Manager <br /> PHONE# EXT. <br /> BUSINEssNAME Walton Engineering, Inc . ( 91 373-1.166 <br /> FAX# <br /> HOME or MAILING ADpDREESS BOX 1025 ( 91 q 3 7 3-11.7 3 <br /> CITY West Sacramento STATE CA ZIP 85691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 fon-n. <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: G.--- DATE: 3 -013-10 <br /> Compliance Manager <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 1:1OTHERAIJTHORI EDAGENT� Title <br /> If APPLICANT is 'lot the BILLING PARTY proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS:. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already completed); <br /> SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> [invoice## Check# Received By: <br /> Payment Type <br /> SR FORM(Golden Rad) <br /> EHD 48-02-025 <br /> REVISED 11/17!2003 <br />