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SAN JOAQUI�OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 600 rQj(� 'K 601 <br /> v� Z� <br /> OWNER/OPERATOR 7-Eleven Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 7-Eleven #35355 <br /> SITE ADDRESS 3202 W Hammer Lane Stockton95209 <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 —(916)373-1173 <br /> CITY West Sacramento STATE CA ZIP 95620 <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: &41�- Aum DATE: 8/19/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [X Contractor <br /> It 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 /> 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: �-�' PAYMENT <br /> COMMENTS: <br /> AUG 2 0 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1Q P 1 E: <br /> �Fee Amount: 0,� Amount Paid 3 ! C7 v Payment Date V'� <br /> Payment Type C Invoice# Check# S Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />