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SAN JOAO0".%:'eOUNTy ENVIRONMENTAL HEALTA <br /> PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station o C9 C6 ' <br /> OWNER/OPERATOR 7-Eleven,Inc. CHECKif BILLING ADDRES§0 <br /> FACILITY NAME <br /> 7-Eleven#35355 <br /> SITEADDRESS 3202 W Hammer Lane Stockton 95209 <br /> Street Number I Di I Street Name Ctty Zia Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strut Number §kew Name <br /> CITY STATE zip <br /> PHONE#1 EXT. AP NN LAND USE APPLICATION# <br /> 02-- ?z2n -10 - <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECK If BILLING ADDRESSIM <br /> BUSINESS NAME PHONE# <br /> Walton Engineering,Inc. (916) 373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916) 373-1173 <br /> CITY STATE 71P <br /> L— West Sacramento CA 95691 <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 or <br /> 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: 030 1'M14 <br /> [3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT [X Contractor <br /> If AppucAmT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> as,7 <br /> COMMENTS: 7* <br /> AU b 0 8r i-11 I A014 <br /> �4 <br /> 77Y 0 <br /> A <br /> #V <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 44 , 4,1 <br /> ASSIGNED TO- EMPLOYEE#: "3 <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 43 Amount Paid!-�'7 <br /> 5,DD I Payment Date <br /> Payment Type Invoice Check# <br /> — Received By: <br /> 1,/ 4�77E <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> 07117/08 <br />