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IF SAN JOAQUI. OUNTY ENVIRONMENTAL HEALTF ,PARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel CHECK if BILLING ADDRESS FACILITY ID # L/lr SERVICE REQUEST # `5"O(v434,9 OWNER/ OPERATOR 7 -Eleven Inc . CHECK if BILLING ADDRESS E] FACILITY NAME 7 -Eleven #2369-19976 (916)373-1166 SITE ADDRESS 1399 Street Number N Direction Main Street Street Name P.O. Box 1025 Manteca Ci 95337 Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number STATE CA ZIP 95691 Street Name CITY Z3 -7S. OLD STATE ZIP PHONE #1 EXT. ( ) Invoice # API # LAND USE APPLICATION # PHONE #L EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan CHECK if BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. I FEB 10 2012 "0 JppQ NME1(tAL H� DEPARTMENT PHONE# EXT. EMPLOYEE #: 0 (916)373-1166 HOME or MAILING ADDRESS FAX # P.O. Box 1025 Date Service Completed (if already completed): (916)-373-1173 CIN West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:1 �_/t DATE: PROPERTY /BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 0 Compliance Manager If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. n .v%AENT TYPE OF SERVICE REQUESTED: rrl RECEIVED COMMENTS: I FEB 10 2012 "0 JppQ NME1(tAL H� DEPARTMENT ACCEPTED BY: EMPLOYEE #: 0 DATE: 2-1f p (Z ASSIGNED TO: - / EMPLOYEE #: (-; DATE: Z t c) (i Z Date Service Completed (if already completed): SERVICE CODE: C3� (L, --7P/E: )- 3 C6 Fee Amount: fir' Amount Paid Z3 -7S. OLD Payment Date 10 1 -2— Payment Payment Type Invoice # Check # Lt SI - f L� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003