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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 <br /> OWNER I OPERATOR <br /> 7-Eleven, Inc. CHECK If BILLING ADDRESS ED <br /> FACILITY NAME 7-Eleven #17334 <br /> SITE ADDRESS 4501 1 North Pershing Ave Stockton 95207 <br /> street Number I Direction Street Name City Zip Carle <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 Enc BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CNECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Exr. <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME Or MAILING ADDRESS P.O. Box 1025 (916 ) 373-1172 <br /> CITY West Sacramento STATE CA aP 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA arld FEDERALVlaws. <br /> APPLICANT'S SIGNATURE: �'1////I DATE: /0,�// } <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> OCT 0 6 2017 <br /> ENVIRONMENTAL HEALTH <br /> ACCEPTED BY: EMPLOYEE#: q , <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: p 1 E. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />