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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # IIERVIC+E' /REQUEST # <br /> Car Wash / Gas Station <br /> OWNER / OPERATOR <br /> Pat Byrne CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> ZOOM Car Wash <br /> SITE ADDRESS 3434 E Hammer Lane Stockton , CA 95212 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #t EXT• APN # LAND USE APPLICATION # <br /> ( ) 916 -296 -9959 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Baylis Y CHECK If BILLING ADDRESS LOJ <br /> BUSINESS NAME PHONE # EXT , <br /> IEC Services 650 . 969 . 9616 <br /> HOME or MAILING ADDRESS 4901 Warehouse Way FAX # <br /> CITY Sacramento STATE CA ZIP 95826 <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 /> 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 : 11 /5 /21 <br /> PROPERTY / BUSINESS OWNER ❑ OP RATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ix 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 . PA lem <br /> TYPE OF SERVICE REQUESTED : LIST /Z i0 7&V <br /> COMMENTS : S4 /VF A '0 <br /> ' Y V <br /> 10 <br /> H q NL Ro U/ COO , <br /> ryo p4&� oNTy <br /> ACCEPTED BY : '\ /� EMPLOYEE # : DATE: ' 2�j <br /> ASSIGNED TO ' h t c,t3 �) fv �1 a EMPLOYEE #: DATE : �j/ <br /> Date Service Completed ( if already completed) : SERVICE CODE : P I E:2� � <br /> Fee Amount : o Amount PaidPayment Date <br /> � J Ob I <br /> Payment Type `S � Invoice # Check # 3 Z Receive By : <br /> EHD 4 &02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />