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SAN JOAQUI16OUNTY ENVIRONMENTAL HEALTWEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businass or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel -z5 kf S ?00-5'871.5' <br /> OWNER/OPERATOR <br /> 7-Eleven Inc . CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 7-Eleven #20632 <br /> SITE ADDRESS 4627 DaVinci Avenue Stockton 95207 <br /> Street Number I D rection Street Name city Zip 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 /> 62-0-4 3 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . PHggt 373-1166 EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 916) 373-1172 <br /> CITY West 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,,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: +�,�,�_ DATE: 1 0`, <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3: Compliance Manager <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 <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. f� <br /> TYPE OF SERVICE REQUESTED: IA-ST 64�4( i�- <br /> COMMENTS: PACE.vE� <br /> NOV _ 3 2009 NOV 1 2009 <br /> SAENORONME IRONNItNT HEALTH! <br /> HEjq--I}{DEFAR <br /> ACCEPTED BY: © ut v [ EMPLOYEE#: C) &'2-1 DATE: / 3/09 <br /> ASSIGNED TO: A—c Lt-E EMPLOYEE#: i--�P 3 fj DATE: 0 <br /> Date Service Completed (if already completed): SERVICE CODE: ( q r3 P A:':�3 U <br /> Fee Amount: Ln-) Amount Paid 34 5 FPayrnent Date \\ 3 6 <br /> Payment Type ✓ Invoice# Check# L 1�5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />