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SAN JOAQUII*UNTY ENVIRONMENTAL HEALTHI&PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />7'7x7520()t"2---("3C <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />Pacific Car WashCHECK <br />P <br />if BILLING ADDRESSO <br />FACILI NA T! <br />l�arT et Place <br />FAx # <br />016) <br />SITE ADDRESS 4405 <br />Street Number <br />Direction <br />Pacific <br />Avenue <br />Street Name <br />L`� <br />Stockton <br />city <br />95207 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Date Service Completed (if already completed): <br />Street Name <br />CITY <br />PIE: 2 :S 6fl <br />STATE ZIP <br />PHONE #1 ExT• <br />( 203 478-5504 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />✓ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />/G��%'��%I= — <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Walton Engineering, Inc. <br />P <br />373-1166 Exr. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />FAx # <br />016) <br />373-1173 <br />CITY West Sacramento <br />STATE CA <br />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 <br />or 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 and FEDERAL laws. i <br />APPLICANT'S SIGNATURE: �'"—�/1� DATE: <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L? Compliance Manager <br />If APPLICANT is not the BILLf1VG PAR 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAVM FNT <br />TYPE OF SERVICE REQUESTED: /�<S( <br />/G��%'��%I= — <br />RECEIVED <br />COMMENTS: <br />MAY 2 7 2011 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />GTIj <br />DATE: Z7 ( t <br />ASSIGNED TO: <br />L`� <br />EMPLOYEE #: <br />6 �rc^ <br />DATE: S—/2-7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: Cq�f <br />PIE: 2 :S 6fl <br />Fee Amount: <br />3 L, _ o1) <br />Amount Paid 3 LL . p (--) <br />Payment Date Z7// / <br />Payment Type <br />✓ <br />Invoice # <br />Check # Ltq <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />