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t �XN JOAQLCOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> as station L�-�� �P-60 'SJ, 0o <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 7-Eleven Inc . <br /> FACILITY NAME <br /> 7-Eleven #20632 <br /> SITE ADDRESS 4627 Da Vinci Drive Stockton 95207 <br /> Street Number 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 0 <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 /> DITMWest Sacramento 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 <br /> or 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,S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/3/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® contractor <br /> IfAPPL/CANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 05 <br /> COMMENTS: <br /> :® <br /> OCT ^ r <br /> SAN Jt'? fir: •, I'F',I Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: / <br /> ASSIGNED TO: '�` EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I E: b <br /> Fee Amount: Amount Paid Payment Date is 4l k <br /> Payment Type Invoice# Check# Receiv d B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />