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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility / j� � <br /> OWNER / OPERATOR 7 - Eleven , Inc . CHECK if BILLING ADDRESS <br /> FACILITY NAME 7 _ Eleven #32262 <br /> SITEADDRESS 2360 West Grantline Rd . Tracy 95376 <br /> Street Number Direction Street Name city Zio 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 /> 0t 1 <br /> PHONE #Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE # EXT, <br /> Walton Engineering , Inc . 916 373 - 1165 <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 : i DATE ; c4 <br /> PROPERTY / BUSINESS OWNER ❑ OP RATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <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 4 <br /> ime it is <br /> provided to me or my representative . <br /> wi <br /> TYPE OF SERVICE REQUESTED : 4Ah <br /> COMMENTS : S,q11N <br /> i h��R NM C �0�9 <br />� MFNr <br /> ACCEPTED BY : EMPLOYEE M \ lu� DATE : 4 3(t ( q <br /> ajASSIGNED TO : EMPLOYEE # : v� DATE : ( 1q <br /> Date Service Completed ( if already completed) : SERVICE CODE : Gt I5 P / E: J2509 <br /> Fee Amount: 45 Amount Paid �lS� )v Payment Date <br /> Payment Type Invoice # Check # Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />