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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE RR7EQUEST # <br /> Gas Dispensing Facility <br /> OWNER./ OPERATOR <br /> 7-Eleven, Inc CHECK If BILLING AODRRiS <br /> FACILITY NAME 7-Eleven, Inc. Store # 41342 <br /> SITE ADDRESS 1233 E. DR. MARTIN LUTHER KING JR. BLVD: Stockton 95205 f <br /> Streot Number O roc Ion Street Name t I Code <br /> HOME Or MAILING ADDRESS (ir Different. from Site Address) <br /> P .O. Box 711 Attn : Gasoline Corn /lance Street Number sleet Hemp <br /> CITY Dallas STATE Te zip 75221 -0711 <br /> PRONEM ExT. APN # LAND USE APPLICATION # <br /> (916 ) 742-0232 151 -370-180-000 <br /> PHONE#2 Exi. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS_ <br /> Grace Esplin on behalf of 7-Eleven , Inc. <br /> BUSINESS NAME Tait & Associates, Inc. PRONE#6 ExT. . <br /> 91669-' 1838 <br /> HOME or MAILING ADDRESS FAx# <br /> 11280 Trade Center Dr. ( ) <br /> CITY Rancho Cordova STATE CA ZIP 95742 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH- DEPARTMENT hourly Charges associatedwith 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 ap II if and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Slandal Ar and RAL laws. �� <br /> APPLICANT'S SIGNATURE: DATE: _ <br /> PROPERTY I.BUSINESS OWNER EJ OPERATOR / MANAGER ❑ OTHER AUTHORIZEOAGENT ❑ Construction Manager <br /> /(APPLICANT i5 not the BILLING PARTY Proof of authorization t0 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 InforlT�ttll <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It is provided tryk <br /> my representative. <br /> TYPE OF SERVICE REQUESTED; GW N S / .- tf` `O <br /> COMMENTS: ^ SANC, OS <br /> lYFgy � TMgDFN�DjF?NN0TNRIi <br /> ACCEPTED BY: J -�r �\ rn EMPLOYEE #: DATE: <br /> ASSIGNED TO: EMPLOYEEM DATE:/Q <br /> Date Service Completed (It ady completed): SERVICE CODE: 03 PI E:/ l <br /> Fee Amount: O CPO Amount P 3 0� d(/ Payment Pate ZQ 1 <br /> Payment Type Invoice # Check # Recqfved By: <br /> EHD 48-02-026 SR FORM (GoldenRod) <br /> 07/17/08 <br />