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SAN JOAQUI ;OUNTY ENVIRONMENTAL HEALTI-. .PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />SERVICE REQUEST # <br />SCe)0& 17 7 & <br />OW 7R i OPERATOR 7 -Eleven Inc . <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME 7 -Eleven #2369-19976 <br />1 <br />SAN JOAQUN COUNvy <br />SITE ADDRESS <br />Street Number <br />Direction <br />Main Street <br />Street Name <br />ACCEPTED BY: <br />Manteca <br />city <br />95337 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: do& 7C <br />Street Name <br />CITY <br />STATE CA <br />STATE ZIP <br />PHONE #1 ExT• <br />( ) <br />P 1 E: _4:30t <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />Payment Date <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />PHONE# <br />ExT. <br />1 <br />SAN JOAQUN COUNvy <br />(916)373-1166 <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: <br />FAX # <br />DATE: % 112— }-o I <br />P.O. Box 1025 <br />EMPLOYEE #: do& 7C <br />(916)-373-1173 <br />CITY West Sacramento <br />STATE CA <br />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:.-,L/L fes_ C DATE: (' - <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT [3 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: US 02Ej"/'�aG j 7- <br />PAYMENT <br />COMMENTS: <br />I JAN 122011 <br />1 <br />SAN JOAQUN COUNvy <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: O S <br />DATE: % 112— }-o I <br />ASSIGNED TO: p <br />EMPLOYEE #: do& 7C <br />DATE: (2— rZe, t t <br />Date Service Completed (if already completed): <br />SERVICE CODE: I q ' <br />P 1 E: _4:30t <br />Fee Amount:oo <br />Amount Paid <br />3� <br />Payment Date <br />2 l <br />Payment Type L�— <br />Invoice # <br />Check # S <br />Received By: MT <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />