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ECEIVED <br /> JAN 2 4 2019 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVI�C/En'fREyp'1p1ES q <br /> GAS STATION �A ��U�4^ )�U�/ Id <br /> OWNER I OPERATOR t7' CHECN if BILLING ADDRESS❑ <br /> 7-ELEVEN INC. <br /> FAcRnT NAME 7-ELEVEN <br /> SITE ADDRESS STOCKTON 952 <br /> 4501 seeM Number Dim <br /> ti Zoan <br /> HOME Or MAILING ADDRESS (if Different from SAO Address) <br /> P.O.BOX 711 street Na e <br /> Cm DALLAS STATE CA ZIP 75221-0 1 <br /> PRONE 91 En. APN# LAND USE APPLICATION n ,pP <br /> (800 )2.55-0711 •y`� <br /> PHoNE12 E.. BOS DISTRICT L (�IDr rDE <br /> l ) �YY // <br /> CONTRACTOR/ SERVICE REQUESTOR FNV1 DOW <br /> REDUESTOR KEVIN BROWN CHECK If BILLING <br /> PHONE# Ear. <br /> BUSINESS NAME <br /> LC SERVICES <br /> HOME or MAILING ADDRESS FAX# <br /> 3887 N.VALENTINE ( 1 <br /> CITY FRESNO STATE CA ZIP 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 I have prepared this application and that the work to be perforated will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Statoords,STATE and FEDERAL laws. <br /> �——_ ----- 12/26/18 <br /> APPLICANT'S SIGNATURE: - ��--� - ------_ � DATIE-�:' <br /> PROPERTY t BUSINESS OwNF.R❑ OPERATOR/MANAGER ❑ r OTBER AUTHORIZED AGENT yt AGENT <br /> If APPLICANT is not the BILUNO PL4NT/'.proof of authorization to sign is required • Thle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of tate 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 l0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTii DEPARTMENT as soon as 11 is available and at the same time It is <br /> provided to me or my representative- <br /> TYPE OF SERVICE REQUESTED: Z� 1 <br /> COMMENTS: (0 e P,c..e e LJ 1 S I-e'.,SC �-i N..�t S E� `C/"( (! �r i-O r•-,[ (� <br /> '` 1 j , I / JAN A 7 2019 <br /> (3�\ IkL I "� <br /> I . <br /> ACCEPTED BY: �/� EMPLOYEE; Rc2o DATE: 1... �t <br /> ASSIGNEDTOC ti KLA..'h a-t/ EMPLOYEE#: �Q,Q DATE: 1 <br /> Date Service Completed (If already completed): SERYICECODE: `-1g PIE: 3C& <br /> Fee Amount: Amount Paid 75(o.d Payment Date <br /> Payment Typo i--,, - invoice# 2±If 8G7G Z9 Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />