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SAN SIO**OUNTY ENVIRONMENTAL HEAD ISPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station t77-51 ZT 00 701 '?3 <br /> OWNERI OPERATOR <br /> 7-Eleven, Inc, CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven#32194 <br /> SITE ADDRESS 4943 S CA-99 Stockton T95215 <br /> Street Number I Direction I Str et Name City Zlo 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 /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECKIf BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAT(# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento STATE CA ZIP 95620 <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 Or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: &1�1- -&- DATE: 07/28/14 <br /> PROPERTY/BUSINESS OWNER 11OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 Contractor <br /> tf 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time it Is provided to me or <br /> my representative. WMEM 11 It: <br /> TYPE OF SERVICE REQUESTED: US 7— t- <br /> 71 1 % RECENE <br /> COMMENTS: <br /> 21014 <br /> JUL 312014 JUL 310 <br /> �,JCAOU,%,�u <br /> RCNkEI�,q My <br /> ENVIRONMENTAL HEALTMAL ° +r xT <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � ,f EMPLOYEE#: DATE: "7 3,c7ic4 <br /> Date Service Completed (if already completed): SERVICE CODE: I Gi(� PIE: 1�� <br /> Alt f ! .7 <br /> Fee Amount: Amount Pald" 3 7.5--bZ�, Payment Date 7 J 4 <br /> Payment Type Invoice# Check# L7L?'3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />