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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Existing 7-Eleven <br /> OWNER/OPERATOR <br /> CHECK II BILLING ADDRESS <br /> 7-Eleven, Inc. X <br /> FACILITY NAME <br /> 7-Eleven <br /> SITE ADDRESS 9110 Thornton Road Stockton 95209 <br /> Street Number I 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 Ear. APN# LAND USE APPLICATION# <br /> ( 1 0"1 Zy 5 020 <br /> PHONE#2 EaT. BOS DISTRICT LOCATION CODE <br /> ( ) 005 of <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Mia Rondone CHECK IT BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ea . <br /> Permit Place 661 857 5620 <br /> HOME or MAILING ADDRESS FAX# <br /> 13400 Riverside Dr#202 1 ) <br /> CITY Sherman Oaks STATE CA ZIP 91423 <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, :ant EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:: 3/10/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTM Permit Expediter <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 an the same time it is <br /> provided to me or my representative. NIC) <br /> TYPE OFSERVICE REQUESTED: Plan Check <br /> COMMENTS: /y�4 <br /> Equipment change for existing 7 Eleven hotdog station. SqN',O <br /> �(AWS �+h (P) - '14 yDQgR/7 aTy <br /> T <br /> ACCEPTED BY: r '_�Y�.-�25�� EMPLOYEE#: DATE: I�� ' p r <br /> ASSIGNED TO: `s µ,ms EMPLOYEE#: DATE: 15- 10 .24 <br /> Date Service Completed (If already completed): SERVICE CODE: S y3 P IE: o t <br /> Fee Amount: 5 i Amount Pal Payment Date <br /> Payment Type � - Invoice# Check# Z Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />