Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTl <br /> SERVICE REQUEST R' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility --T �C U-i,y <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS® <br /> FACILITY NAME 7-Eleven #17334 <br /> SITEADDRESS 4501 1 North Pershing Ave Stockton 95207 <br /> Street m <br /> Nuber Direction Street Name city zi coee <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stmet Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATON If <br /> ( I <br /> PHONE#2 I=. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# E' . <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME Or MAILING ADDRESS P.O. Box 1 025 (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 /> 1 also certify that I have prepared this applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE, d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /0 Z5/1 � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <br /> IfAPPLICANT is not the BILL/NG PARTY proof of authorization to sign is required rine <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: V <br /> COMMENTS: N RECEIVED <br /> OCT 0 6 ppb] OCT 0 6 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL ENATmNaNVIRONMENTAL HEALTH <br /> ACCEPTED BY: Uil EMPLOYEE#:—IAG0i DATE: 1L� <br /> ASSIGNED TO: ��I .. EMPLOYEE#: w•`rl DATE: M1I JO / <br /> Date Service Completed (�N already completed): SERVICE CODE: I C; P I E:1o^ <br /> Fee Amount: (.94 Amount Paid 6 Payment Date 1O 6 oC. <br /> Payment Type Invoice Of Check# Received y: <br /> EHO 48-02-025 (Golden Rod) <br /> REVISED 11/17/2003 s <br />