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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID p ERVIC�t}�Q{� $ <br /> GAS STATION FA 0t�C aq '�JVI'/Il ld <br /> OWNER I OPERATOR <br /> 7-ELEVEN INC. CHECK if BILLING ADDRESS <br /> FACILITY NAME 7-ELEVEN <br /> SrTEADDRESS N E ( cl�-S STOCKTON 952012 <br /> 4501 Stmrtftmber I Din tion Street Name Cit zi otic <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P.O. BOX 711 street Number Street Name <br /> CITY <br /> DALLAS STATE CA IP 7$221-0 1 <br /> PHONE IN EXT_ APNY LA ND USE APPLICATION# <br /> (900 1255-0711 <br /> PHONEN2 En. BOS DISTRICT LOj/JjgM BODE <br /> CONTRACTOR/ SERVICE REQUESTOR FNv°�ouiy <br /> REQUESTOR MD F <br /> KEVIN BROWN CHECK If BILLIN <br /> PRONE# E.I. <br /> BUSINESS NAME LC SERVICES _ <br /> 1710 <br /> HOME Or MAILING ADDRESS FAX 1 <br /> 3887 N.VALENTINE ( ) <br /> CITY FRESNO STATE CA LP 93722 <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 /> 1 also certify that 1 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: 12/28/19 <br /> c. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT DA AGENT <br /> IfAPPLICANT is not the BILLING PARTY'.proof of authorization to sign is required Tide <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 t0 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 /> r I JAN 7 2019 <br /> ACCEPTED BY: e � EMPLOYEE 0: 41'W1 DATE: ,— <br /> ASSIGNED TO: J�, Y��,ri^W EMPLOYEE A: 41"it DATE: I — 1 <br /> Date Service Completed (if already completed): I SERVICE CODE: `y BI P IE: 09 <br /> Fee Amount: Amount Paid dd Payment Date <br /> Payment Type � Invoice N c p - 8z7G3q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />