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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility - SKa:�Ci ?)'-�C1 <br /> OWNER/OPERATOR ' <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS® <br /> FACILITY NAME 7-Eleven #17334 <br /> SITEADDRESS 4501 North Pershing Ave Stockton 95207 <br /> Street Number Direction I Street Name city TZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK If BILLINGADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916) 373-1172 <br /> CITY West Sacramento STATE CA ziP 95691 <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 form. <br /> I also certify that I have prepared this application nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® C �� A-C o M— <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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. P <br /> TYPE OF SERVICE REQUESTED: �t ' i r CP, <br /> COMMENTS: //t <br /> �N!DA 8 3 ?418 <br /> FNvt QU/N <br /> yE'gLTy4 pMj 04t <br /> NT <br /> ACCEPTED BY: \ EMPLOYEE#: Ci J I DATE: <br /> I vim <br /> ASSIGNED TO: j n/���1 EMPLOYEE#: G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C� P 1 E: <br /> Fee Amount: Amount Pal Payment Date 7 3 <br /> Payment Type Invoice# Check# 53733 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />