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SAN JOAQUIl�COUNTY ENVIRONMENTAL HEAL T EPARTMENT U4 SERVICE REQUEST Type of Business or Prope FACILITY ID # SERVICE REQUEST # _ BUSINESS NAME K�L)l 5 + OWNER / OPERATOR Walton Engineering, Inc. ❑ 7 -Eleven, Inc . CHECK if BILLING ADDRESS FACILITY NAME P.O. Box 1025 ASSIGNED TO: wo 7-Eleven35355 CITY West CIrYWest Sacramento STATE CA ZIP SITEADDRESS 3202 West Hammer Lane Stockton Fee Amount: -°'� 95209 Street Number Directiona Invoice # e Received By: . i C ode HOME or MAILING ADDRESS (If Different from Site Address) P .0. BOX 711 Street Number Street Name CITY Dallas STATE ZIP TX 75221 PHONE #1 EXT. ( 1 APN # LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS BUSINESS NAME FEB 14 2013 PHONE# EXT• Walton Engineering, Inc. (916)373-1167 HOME or MAILING ADDRESS FAX # P.O. Box 1025 ASSIGNED TO: wo 916) 7 - (916)373-1162 CITY West CIrYWest Sacramento STATE CA ZIP 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: d I / A C�'�� DATE: . DI S D l o PROPERTY / BUSINESS ONifiER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® contractor If APPLic.4,w 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 salve time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: IRECEIVED FEB 14 2013 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH ACCEPTED BY: EMPLOYEE #: DATE: Z"Z ASSIGNED TO: wo EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: O Fee Amount: -°'� Amount Paid 3-X. _- Payment Date A4116, Payment Type �/ Invoice # Check # 4(P ZD Received By: . EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003