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SAN JOAQUINUNTY ENVKIONMENTAL HEALTH ARTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel C-00J917 73 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 7-Eleven #2368-32190 <br /> SITE ADDRESS 4943S State Hwy 99 Stockton 95215 <br /> Street Number etlan I Street Name city ZID Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P.0- Box 711 <br /> Street Number Street Name <br /> CITY Dallas STATE TX ZIP 75221 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209 939-0679 3fo-Lor <br /> PHONE#2 ExT. BOS DISTRICT ^ LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb - Compliance Manager CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . PHONE# En. <br /> 91 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 911 373-1173 <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. Cl <br /> APPLICANT'S SIGNATURE: DATE�}:: , - 1 - <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT0 Compliance Manager <br /> If APPLICANT is not the BlLLlNG PARTr 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 avallab (d at the same time it is <br /> provided to me or my representative. M w <br /> TYPE OF SERVICE REQUESTED: [A-S 7- �G 9 <br /> COMMENTS: ```� CA r <br /> JV �0 0NM� <br /> S��SNpte <br /> H ! <br /> ACCEPTED BY: D ��SEL i`-A EMPLOYEE g DATE: '1O <br /> ASSIGNED TO: ^/A-(OL( EMPLOYEE M Q DATE: -7 09 <br /> —1 <br /> Date Service Completed (if already completed): SERVICE CODE: /Glf1 I PIE: <br /> Fee Amount: Amount Paid -ff> 3) S' v Payment Date 7 <br /> Payment Type ✓ Invoice# Check# it)Lip 41 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />