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SAN JOAQIICOUNTY ENVIRONMENTAL HEALTPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 1917 S� <br /> OWNER/OPERATOR <br /> 7-Eleven,Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven#35355 <br /> SITE ADDRESS 3202W Hammer Lane —F—Stockton F95209 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number F Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> c ) 0C i3 b► D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION <br /> pp CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> Veronica Freitas CHECKIf BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916)373-1163 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916) 373-1171 <br /> CITY West Sacramento STATE CA ZIP 95620 <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 /> 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: A& DATE: 11/20/2014 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sigh 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 /> rK <br /> TYPE OF SERVICE REQUESTED: 4(:57- RFC EN) <br /> COMMENTS: AIDV <br /> � 0A. <br /> ACCEPTED BY: �- EMPLOYEE#: DATE: <br /> ASSIGNED TO: Z�1-�Q,�EF EMPLOYEE#: OOOS DATE: // Z/ / <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E:.230 00 <br /> Fee Amount: D Amount Paid ,3qo DD Payment Date �C <br /> Payment Type s Invoice# Check# 4/9' 9-0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />