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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Dispensing Facility <br /> OWNER / OPERATOR <br /> 7 -Eleven , Inc CHECKIf BILLING ADDRESS <br /> FACILITY NAME 7 - Eleven , Inc . Store # 41187 <br /> SITE ADDRESS N Stockton 55205 <br /> 1829 Street Number Direction Wilson WaytiName Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address ) <br /> RID , Box 711 — Attn ; Gasoline Compliance street Number street a <br /> CITY Dallas STATE Zip 75221 -0711 <br /> TX <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (916 ) 742 - 0232 117 - 150 - 290 - 000 <br /> PHONE #2 EXT. BOS DISTRICT® ®� LOC CO E <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLINGADDRESS <br /> ff <br /> Lacy Dodge on behalf of 7 - Eleven , Inc . 11 <br /> BUSINESS NAME PHONE # Ext. <br /> Tait & Associates P1 (1 ) 6e9 - 1849 <br /> HOME or MAILING ADDRESS FAX # <br /> 11280 Trade Center Dr . ( ) <br /> CITY Rancho Cordova STATE CA ZIP 95742 <br /> BILL LNG ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project specific ENVIRONNIENTAL HEALTH DEPARTisENT 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 JOACUII•d <br /> COUNTY Ordinance Codes, Standards , TE d FEDERAL Jaws . ( � + <br /> APPLICANT' S SIGNATUREi DATE : `� n <br /> PROPERTY I BUSINESS OWNER ERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLY11S PAPTV, proof of authorization to sign Is required Tarr <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 /> t0 the SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me of <br /> my representative . <br /> TYPE OF t <br /> L Ll <br /> COMMENT RECEIVED � �,1 " <br /> JUi� � Z (j 'lll <br /> JUL 0 3 2020 <br /> � i �� l <br /> SAN JOAQUIN COUNTY r� Oi'NIltfiB <br /> ENVIRONMENTAL I, i 4 " Iii m g\,j <br /> ACC EMPLOYEE M DATE ; <br /> ASSIGNED T0 ; C� " ��/ EMPLOYEE #; DATE ' 7 � <br /> Date Service Completed ( if already completed) ; SERVICE CODE ; 4 P l E ; 230 <br /> Fee Amount ; <br /> Amount Palcf _ Payment Date <br /> Payment Type 4 Invoice # Check # ` # l Received By <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />