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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 / Gasoline Station FA" 9d Q l- > D 0 S "2 (0 � <br /> OWNER / OPERATOR <br /> Paula Sime CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> 7- Eleven , Store # 17334 <br /> SITE ADDRESS <br /> 4501 N Pershing Avenue Stockton 95207 <br /> Street Number Direction Street Name citvZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address ) ^ <br /> PO BOX 1 (726 Street Number Street Name ' 1 ,N <br /> CITY STATE zip T <br /> Temecula CA 92593 C V4 <br /> PHONE #1 EXT, qpN # LAND USE APPLICATION # Cr <br /> ( 951 ) 395-2710 S l 0202? <br /> PHONE #2 EXT. BOS DISTRICT LO <br /> ( ) ��ACTN p NMS q�NTY <br /> CONTRACTOR / SERVICE REQUESTOR TM�Nr <br /> REQUESTOR <br /> Alex Flink CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Innovative Construction Solutions ICS 925 574-2606 <br /> HOME or MAILING ADDRESS FAX # <br /> 2525 Stanwell Drive Suite 200 ( ) <br /> CITY Concord CA STATE 94520 <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 /> 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 <br /> COUNTY Ordinance Codes , Standards, STATE an EDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE : 9/29/2022 <br /> PROPERTY I BUSINESS OWNER ❑ OPERA OR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Project Coordinator <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to 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 information <br /> t0 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 /> ICS is requesting service from EHD for decommissioning two (2) 10 , 000 -gallon USTs at the above site to also include the <br /> demolition of associated piping , fuel dispensers and overhead canopy at the fueling station . <br /> ACCEPTED BY : EMPLOYEE #: DATE: <br /> ASSIGNED TO : EMPLOYEE #: DATE : <br /> /! tnD 7J_ Jz� <br /> Date Service Completed ( if already completed) : - � SERVICECODE: ��2GI PIE: <br /> Fee Amount: Amount Pai 6? ( Payment Date � L) , � ZZ <br /> Payment Type ��— Invoice # Check # �SbB �Dt}-� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />