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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GAS DISPENSING FACILITY Of oc) `/� <br /> �� „l r ,r <br /> OWNER / OPERATOR V <br /> STHEM , LLC CHECKIf BILLING ADDRESS [] <br /> FACILITY NAME <br /> PACIFIC CAR WASH <br /> SITE ADDRESS <br /> 4415 PACIFIC AVE . STOCKTON 95207 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 300 FRANK OGAWA PLAZA , SUITE 3 <br /> Street Number Street Name <br /> CITY STATE Zip <br /> OAKLAND CA 94612 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 510 ) 268-8500 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsk - Construction Manager <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT , <br /> WALTON ENGINEERING 916 373- 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> PO BOX 1025 ( ) <br /> CITY STATECA ZIP <br /> WEST SACRAMENTO <br /> 9569 <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 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 . <br /> APPLICANT'S SIGNATURE : DATE : 06/ 17/20 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ THER AUTHORIZED AGENT it CONSTRUCTION MANAGER <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 /> civ <br /> SAN ✓JUC o6 ?0?0 <br /> yFA TNR NMF �t�N <br /> ACCEPTED BY: nt / , �J `1 ! // va EMPLOYEE #: DATE: / i �� <br /> ASSIGNED TO : NG��LL 'W�F'vl G�� EMPLOYEE # : DATE : � IL� h <br /> Date Service Completed ( if already completed) : SERVICE CODE : I q p PIE : <br /> IE : 2G�GO Q <br /> ;1 <br /> Fee Amount: VT Amount Pal � v Payment Date 72; Q <br /> Payment Type Invoice # Check # SG (o Recei ed By : <br /> EC0 <br /> D 48$02-025 <br /> 07/17/08 <br /> SR FORM (Golden Rod) <br />