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SAN JOAQUI OUNTY EN-11RONMENTAL HEALT-"EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel --7 �56 -,r40052'7-7 / <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 7-Eleven #2368-32190 <br /> SITE ADDRESS 4943 S State Hwy 99 Stockton 95215 <br /> Street Number I Direction I C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 711 <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 1741-.310 -o/ <br /> PHONE#2 En. BOS DISTRICT <br /> ( ) � LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dulcinea Webb - Compliance Manager CHECK if BILLING ADDRESS❑ <br /> BUSINESSNAME Walton Engineering, Inc. PHONE# EXT. <br /> 91q 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 91(y 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 ENviRoNMBNTAL 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,Standar and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ._f� 0 DATE: <br /> � <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ LJ OTHER AUTHORIZED AGENT Compliance Manager <br /> If APDL/CANT 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: (�$ I Pe A./6" 02-OE yO 4-C 1-4-1 <br /> COMMENTS: PAYMENT RECEIVED <br /> �f ED <br /> RECEIVED <br /> NOV 16 2009 NAV 13 2009 <br /> SAN JOAQUIN COUNTY ENVIRONMENT HEALTH <br /> ACCEPTED BY: OLCVEC�r¢ �NLPA41tifED#PAFTfy !3 0 <br /> ASSIGNED TO: /.,/f�/,0 u EMPLOYEE M 2CP"Zr{ /Q DATE: 11T <br /> 0 <br /> ,v <br /> Date Service Completed (if already completed): SERVICE CODE: r 4 6 1 PIE:,220& <br /> Fee Amount: 34 ,r,,l) Amount Paid X345 O� Payment Date IL O <br /> Payment Type Invoice# Check# Zfl I Z Received y: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />