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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 F&OCU 7 �� �y is I <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> 7- Eleven , Inc . <br /> FACILITY NAME <br /> 7 - Eleven #32262 <br /> SIT6D Ess W. Grant Line Rd , Tracy 95377 <br /> Street Number Direction Street Name city Zip 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 /> bo r <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering , Inc . PHONE # EXT. <br /> ( 916 ) 373- 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> PO BOX 1025 <br /> ( 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 or <br /> 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 <br /> Eaand <br /> �,FEDERAL laws . p <br /> APPLICANT' S SIGNATURE : �� yR LVAU �AIW DATE : 2` <br /> Construction Mana er <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT g <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it Is provided to me or <br /> my representative . PAYMENT <br /> TYPE OF SERVICE REQUESTED : �A.r / l ' t " REC <br /> tivAfteka <br /> COMMENTS : AuG 28110 <br /> NSn ENO ryONrNEN PLTY <br /> HLnLTH UEPIIRT MENT <br /> ACCEPTED BY : YV EMPLOYEE #: DATE: /J �Zzi <br /> L <br /> ASSIGNED TO : /► EMPLOYEE # : DATE : 2 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : / q(f 2yU F IJP / Es 2 <br /> Fee Amount : B Ct Amount Paid Payment Date v <br /> Payment Type Invoice # Check # 6? Received By : <br /> EHD 48 -02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />