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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # 2 SERVICE REQUEST # <br /> GAS DISPENSING FACILITY (1 ( 52 God <br /> OWNER / OPERATOR <br /> STH EM , LLC CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> PACIFIC CAR WASH <br /> SITE ADDRESS <br /> 441p5 PACIFIC AVE . STOCKTON 95207 <br /> Street NumberDirection 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 2 +.� ® I <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) a L0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 STATE CA ZIP <br /> WEST SACRAMENTO95691 <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 and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : Qb 40 ft&I DATE : 06/ 17/20 <br /> �T <br /> PROPERTY / BUSINESS OWNER ElOPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Z( 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 t0 me or <br /> my representative . bA <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: O <br /> SgNJJ�C 03 20 <br /> y�A��HO NMFNoCI TY <br /> q C <br /> ACCEPTED BY : 1r' -) �j EMPLOYEE # : DATE : i h7C� r <br /> ASSIGNED TO : pr /V`J EMPLOYEE # : DATE : <br /> t� <br /> Date Service Completed ( if already completed) : SERVICE CODE : ! PI E : <br /> Fee Amount : // �2 � co Amount Pai � , V � Payment Date <br /> Payment Type f- Invoice # Check # / U D ecei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />