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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Station �0ay ?dN t0 <br /> OWNER/OPERATOR <br /> CHECK if BILLING AUDRESS13 <br /> FACILITY NAME 7-Eleven Inc#38616 <br /> SITE ADDRESS 601Carolyn Weston Blvd. Stockton 95206 <br /> Street Numher Direction Street Name Cit ZiD Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> PO Box 711:Attn:Gasoline Department <br /> Street Number Street Name <br /> CITY STATE zip <br /> Dallas TX 75221 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (972 ) 828-7930 - - —_ <br /> PHONE#2 Ext. BOS DISTRICTLOCATION CODE <br /> (916 ) 340-4162 11 <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> REQUESTOR Crystal Justice J CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME 7-Eleven PHONE# EXT' <br /> 916)742-0232 <br /> HOME or MAILING ADDRESS 3860 Broadway Street,Suite 110 FAX# <br /> CITY - - STATE CA Zip <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared thisap lie ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,5T TNa DERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: 12/22/2020 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 77/h, <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERIACECODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />