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SAN JOAQUI— -:OUNTY ENVIRONMENTAL HEALTHORPART .� O (] <br />SERVICE REQUEST <br />(0 1P <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />ki u <br />V <br />SERVICE REQUEST # <br />Lt <br />OWNER / OPERATOR 7 -Eleven Inc. <br />CHECK if BILLING ADDRESS E] <br />FACILITY NAME 7 -Eleven #2369-19976 <br />PHONE# EXT. <br />SITE ADDRESS1�22 - <br />SAW '.& <br />N <br />Direction <br />Main Street <br />Street Name <br />HOME or MAILING ADDRESS <br />Manteca <br />city <br />95337 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street NumberF <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Paid <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />COMMENTS: <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />NOV 15 2012 <br />PHONE# EXT. <br />SAM JOAQUIN COUNW <br />(916)373-1166 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: <br />FAX# <br />P.O. Box 1025 <br />EMPLOYEE #: <br />(916)-373-1173 <br />CITY West Sacramento <br />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: Q) -\ L <br />PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Manager <br />If APPLICANT 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: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />NOV 15 2012 <br />SAM JOAQUIN COUNW <br />ENVIROMENTAC <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: 7J `Amount <br />Paid <br />Payment Date <br />Payment Type Invoice # <br />Check # .7� <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />