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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK FACILITY ID # SERVICE REQUEST # 7 -Eleven Convenience Store PHONE# �j Err HOME or MAILING ADDRESS (� FAX# ACCEPTED BY: Vidal Pedraza STATE c AI CITY `^ P\\—\O, zip GN' —\os DATE: 5_26_2 ASSIGNED TO: Kadeanne Linhares OWNER/OPERATOR 7 -Eleven, Inc CHECK If BILLING Date Service Completed IN already Completed): ADDRESS❑ FACILITY NAME Fee Amount: 456 Amount Pai4 75 e �� 7 -Eleven #41531 Payment Type Invoice # SITE ADDRESS N Tracy Blvd. Tracy 95376 3379 Sireel Number D'rectlon Name Cft zJP Code HOME or MAILING ADDRESS (If Different from Site Address) P.O. BOX 0711 SVeet Numeer treat Name CITY Dallas .X STATE zip 75221 PHONE#1 ET' APN# LAND USE APPLICATION# (916) 742-0232 214-180-210 PHONE #2 E.. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK \\p � �r If BILLING ADDRESS BUSINESS NAME f \ ` PHONE# �j Err HOME or MAILING ADDRESS (� FAX# ACCEPTED BY: Vidal Pedraza STATE c AI CITY `^ P\\—\O, zip GN' —\os BILLING ACKNOWLEDGEMENT: I, 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. 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, TTEE and FEOERA/yJgw\s. APPLICANT'S SIGNATURE: (, X �l J DATE: T `�� PROPERTY I BUSINESS OWNER ® OPERATOR (MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I%APPLICANT is not the BILLING PARK proof of authorization to sign Is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 tim" "s provided to me or my representative. � TYPE OF SERVICE REQUESTED: C ' COMMENTS: Mq y O Health Permit plan review for 7 -Eleven convenience store. r S-41y� hF CTy4Qo R n<?�). ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 5_26_2 ASSIGNED TO: Kadeanne Linhares EMPLOYEE#: 4589 DATE: 5-26-21 Date Service Completed IN already Completed): SERVICECODE: 523 PIE: 1601 Fee Amount: 456 Amount Pai4 75 e �� Payment Date S Payment Type Invoice # Check # Ir 710 Received By: Afft- EHD 48-02-025 SR FORM (Golden Roo) 07/17/08