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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 r I ,> <br /> OWNER / OPERATOR <br /> 7- Eleven , Inc , CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven #41342 <br /> SITE ADDRESS <br /> 1233 Dr, MILK Jr. 131vd . Stockton 95205 <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 /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTO <br /> REQUESTOR Ef <br /> Sarah JablonskY ' Construction Manager <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering , Inc. PHONE # EXT. <br /> 916 373 - 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> PO HOX 10625 <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 /> 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 FEDERAL laws . <br /> APPLICANT' S SIGNATURE : WI ' 4WAI ' DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Construction Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign /s 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 . <br /> TYPE OF SERVICE REQUESTED , , <br /> COMMENTS <br /> Sep <br /> N� q TND * COUIV <br /> SRT � <br /> ACCEPTED BY: `a EMPLOYEE M DATE : 3 <br /> ASSIGNED TO : <br /> -- EMPLOYEE #: DATE <br /> Date Service Completed ( if already completed) : SERVICE CODE PIE . ' L <br /> Fee Amount : 77 <br /> Amount Paid ; Payment Date <br /> Payment Type Invoice # Check # � Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />