Laserfiche WebLink
SAN JOAQUIr OUNTY ENVIRONMENTAL HEALT" EPARTMENT <br /> SERV-4 LNZEQUEST <br /> Type of Business or Property " FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel 2— VG 5(tcol j;�S0Y <br /> OWNER/'OPERATOR <br /> 7—Eleven Inc . CHECK IfBILLING ADDRESS <br /> ❑ <br /> FACILITY NAME 7-Eleven #2368-14117 <br /> SITE ADDRESS 2725 1 1 Country Club Auiv Stockton 95201 <br /> Street Number Direction Street NameCit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) l 2-1 - Zl© -0�, <br /> PHONE#2 EXT, BOS DISTRICT LOCATION BODE <br /> ( .3 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Dul c inea Webb-Covan CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Walton Engineering, Inc . PHONE# EXT. <br /> ( 916) 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P .O . Box 1025 ( 916)-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: - (�✓�—^ DATrF: ` I `' I V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTIIORIZEU AGENT Lf Compliance Manager <br /> If APPLICANT is not the BILLING DARTY,proof Of authorization to sign is required Tette <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 ENVIRONMFNrAL 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: r i Tj PAYMENT <br /> COMMENTS: <br /> MAR 12 2010 <br /> SAN jgAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n r L v Er EMPLOYEE#; �_3 � DATE: <br /> ASSIGNED TO: v ok) +tel^(( EMPLOYEE M r--317 DATE: f Z (fj <br /> Date Service Completed (if already Completed): SERVICE CODE: r C� PIE- -�0 <br /> Fee Amount: Tq L-5-,")0 Amount Paid s Payment Date Z <br /> Payment Type �� Invoice# Gheck# Received By: W- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />