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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CEli <br />ft <br />FACILITY ID # <br />CHECK If BILLINGADDRESSE] <br />SERVICE REQUESTtt# <br />Retail Gas Dispensing Facility <br />PHONE# EXT. <br />fl-�6 ���� <br />SKm--7 C) 0 c2 1 <br />OWNER / OPERATOR <br />M NT <br />FAX# <br />7 -Eleven, Inc. <br />EMPLOYEE #: <br />CHECK if BILLING ADDRESS® <br />FACILITY NAME <br />STATE CA ZIP 95691 <br />EMPLOYEE #: <br />7 -Eleven #20632 <br />Date Service Completed (if already completed): <br />SITE ADDRESS 4627 <br />P 1 E: <br />1 Da Vinci Ave <br />Stockton <br />95207 <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DIS�TRIRICT <br />LOCATION CODE <br />( ) <br />CYO <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CEli <br />ft <br />Michael Walton <br />CHECK If BILLINGADDRESSE] <br />BUSINESS NAME <br />O <br />2018 <br />PHONE# EXT. <br />Walton Engineering, Inc. <br />916 373-1165 <br />HOME or MAILING ADDRESS <br />M NT <br />FAX# <br />P.O. Box 1025 <br />EMPLOYEE #: <br />( 916) 373-1172 <br />CITY West Sacramento <br />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 applicatign and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE Ind FEDERAL laws. <br />APPLICANT'S SIGNATURE: PIADATE: — 2 6 — 1 T <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® <br />IfAPPLICANT 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. IJA'yA&rAJ- . <br />TYPE OF SERVICE REQUESTED: <br />CEli <br />ft <br />COMMENTS: <br />MAY <br />O <br />2018 <br />�ROH/N CpUN <br />EALTH Ae <br />M NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: _ 521A <br />ASSIGNED TO: _ _, <br />EMPLOYEE #: <br />DATE: -/ - / <br />Date Service Completed (if already completed): <br />SERVICE CODE: /,98 <br />P 1 E: <br />Fee Amount: pb <br />Amount Paid <br />b� <br />Payment Date S <br />Payment Type 'el <br />Invoice # <br />Check # S3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />