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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS ❑ SERVICE REQUEST # COMMENTS: PHONE# ENT. s� Convenience Store 425 251-6222 S OWNER / OPERATOR FAX# Guggenheim Development Services, LLC. CHECK If BILLING ADDRESS FACILITY NAME 7Eleven ) CITY Kent SITE ADDRESS 1829 N Wilson Way Stockton 95205 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 0, /�µ� S L� EMPLOYEE DATE: 2V 3000 (A / Internet Blvd., Suite 570 Street Number Date Service Completed Street Name CITY SERVICE CODE: STATE ZIP Frisco Fee Amount: TX 75034 PHONE #1 En. APN # Payment Date> t/7 yQ LAND USE APPLICATION # ( 916 )357-6550 117-150-19 Check # b J 7 PHONE R Em ( ) Received By: BOS DISTRICT LOCATON CODE CONTRACTO RVICE REQUESTOR REQUESTOR Caitlin Hepworth CHECK if BILLING ADDRESS ❑ BUSINESS NAME Barghausen Consulting Engineers, Inc. COMMENTS: PHONE# ENT. s� J/r� V�D 425 251-6222 HOME Or MAILING ADDRESS FAX# 18215 72nd Avenue S ( ) CITY Kent STATE WA ZIP 98032 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: jAQFlewd Li/� DATE: 6/16/2020 i PROPERTY /BUSINESSOWNEREI OPERATOR/ MANAGER OTHERAUTHORizEDAGENT 51 Project Planner IJAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative, w TYPE OF SERVICE REQUESTED:// COMMENTS: A rO / C..DYL.✓Y�[LGvI�� �i CNS s� J/r� V�D �� S N1,VgQUI Ht qLTh NAL )Pm- ACCEPTED BY: 0, /�µ� S L� EMPLOYEE DATE: 2V ASSIGNED TO: (A / EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: y rZ7� P I E: (QU Fee Amount: Amount P S �� 77 Payment Date> t/7 yQ Payment Typ Invoice # Check # b J 7 Received By: EHD 25 Fe�r v>�( SR FORM (Golden Rod) REVISED li/17/2003 ��Os�1 i2I