Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> Retail Gas Dispensing Facility ]L.rr}� 9UX Dv� � <br /> OWNER/OPERATOR 7-Eleven, Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME 7-Eleven #17647 <br /> SITE ADDRESS 1048 West Yosemite Manteca 95336 <br /> Street Number Direction Street Name ON Zip Code <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 050: <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK if BILLING ADDRESSO <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: 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. <br /> APPLICANT'S SIGNATURE: DATE: -/ 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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: r4f <br /> in <br /> COMMENTS: <br /> �o �9 ?0�8 <br /> H O U/H C <br /> T"�FpgRo 4 <br /> H 7)- <br /> ACCEPTED BY: ` n An EMPLOYEE#: DATE: ��t^j <br /> ASSIGNED TO: I W► EMPLOYEE#: a DATE: l �j <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: U <br /> Fee Amount: c2 Amount Paid 607Z1410 Payment lDate <br /> Payment Type (J Invoice4f Check# 53-121, ece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />