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SAN JOAQUIN— OUNTY ENVIRONMENTAL HEALTH C ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # BUSINESS NAME APR 222016 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT F (�oC'UCi �Cc� IEP,00--N-7) 9 Gas Station (916)373-1166 HOME Or MAILING ADDRESS OWNER / OPERATOR P.O. Box 1025 Date Service Completed (if already completed): 7 -Eleven, Inc. Crrr West Sacramento CHECK It BILLING ADDRESS FACIUTv NAME 7 -Eleven #2369-17647 Fee Amount: ,7,C1 I Amount Paid SITE ADDRESS 1048 W Yosemite Avenue Manteca 95337 Sbeet Number Check # .o IS 3 I Received By: HOME or MAILING ADDRESS (it Different from Site Address) Street Number Street Name CITY STATE zip PHONE#1 APN# LAND USE APPLICATION# PHONE #2 ExT ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR Veronica Freitas CHECK If BILLING ADDRESS LaJ BUSINESS NAME APR 222016 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT PHONE# E' . Walton Engineering, Inc. EMPLOYEE #: (916)373-1166 HOME Or MAILING ADDRESS FAX # P.O. Box 1025 Date Service Completed (if already completed): (916)373-1173 Crrr West Sacramento STATE CA ZIP 95620 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN CouNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Aw� DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or my representative. TYPE OF SERVICE REQUESTED: P COMMENTS: APR 222016 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: C/-) 1 _ Date Service Completed (if already completed): SERVICE CODE: PIE: a:3Q Fee Amount: ,7,C1 I Amount Paid .C'o I Payment Date 22- I (p Payment Type l vfk— Invoice # Check # .o IS 3 I Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08