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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTIdEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID# <br />SERVICE REQUEST # <br />Gas Station <br />0 U U <br />/Z C E <br />OWNER / OPERATOR <br />Walton Engineering, Inc. <br />7 -Eleven, Inc. <br />HOME or MAILING ADDRESS <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME <br />P.O. Box 1025 <br />7 -Eleven #35355 <br />CITY West Sacramento <br />STATE CA Zip 95691 <br />SITE ADDRESS 3202W <br />SERVICE CODE: ('� <br />Hammer Lane <br />Fee Amount: j '7� ,� <br />Amount Pai <br />Stockton <br />95209 <br />Street Number <br />Direction <br />Street Name <br />Received By: <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />'C) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />Veronica Freitas <br />CHECK if BILLING ADDRESS LW <br />BUSINESS NAME <br />PHONE# ExT. <br />Walton Engineering, Inc. <br />916 373-1167 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: 7 <br />FAX# <br />P.O. Box 1025 <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 or <br />activity will be billed to me or my business as identified on this form. <br />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: <br />PROPERTY / BUSINESS OWNER ❑ <br />DATE: 03.11U'2014 <br />/2014 <br />OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT [2[ Contractor <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 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: — A P14 }� <br />COMMENTS: <br />y�'W'104/Rp UcN Cd <br />ACCEPTED BY: jJ.. /L� <br />G v /T <br />EMPLOYEE #: 7 <br />DATE: ]�' / 4 4, <br />ASSIGNED TO: l T` <br />EMPLOYEE #: 3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ('� <br />PIE: -&0y <br />Fee Amount: j '7� ,� <br />Amount Pai <br />,375,2)Z) <br />Payment Date 3 W <br />Payment Type <br />Invoice # <br />Check # x-7737 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />