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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Piz D/(p Q /p 3�, <br /> Type of Business or Property FACILITY ID# ERVICE REQU #Q <br /> Convenience Store, 7 Eleven D0�� 1{ 5 S� �� O <br /> OWNER/OPERATOR O �h' <br /> P3A Enterprises Inc. CHECKHBILLING ADDRESS <br /> FACILITY NAME <br /> 7 Eleven 17334G <br /> SITE ADDRESS <br /> 4501 N S1.0Number Direction Pershing AVP�ovetName Stockton 95207 zip Cede <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO BOX 219088 <br /> Street Number Street NAME <br /> CITY Dallas STATE TX ZIP 75221 <br /> PHONE#1 Ear. APN# LAND USE APPucATON IF <br /> f 1209-951-6745 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> f I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 7 Eleven Inc. CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> 7 Eleven 17334G <br /> HOME orMAIuxGADDRESS PO BOX 219088 FAX# <br /> l ) <br /> Cm Dallas STATE TX ZIP 75221 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ¢u^Q+", DATE: 09 I DL'1 11 2.D-1I <br /> PROPERTY/BUslNESSO"ERM OPERATOR/MANAGER OTHER AUTHORIzEDAGENT❑ <br /> /fAPPL/CANT is not the BiLL/NO 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 JOAQUEN 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: <br /> COMMENTS: C <br /> A ` Change of ownership inspection Sep?8 G <br /> SAIlijo <br /> Ct�(7`7v� EGGN/PS�, Co/�I �`I�/v� 730-10825 HE N/V A t I EAjOLINT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: Ot FNT <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: (14 OT <br /> Fee Amount: $152 Amount Paidc. �S� cti Payment Date ' <br /> Payment Type CR Invoice# Check# /32 3 — Receiv d By: <br /> EHID 48-02-025 Please call Cathy NlYWFORM(Golden Rod) <br /> REVISED 11/1712003 <br /> 916-730-6825 or email <br /> Cathy@ccgwesl.com with questions <br />