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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Fuel <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />Pacific Car Wash <br />CHECK if BILLING ADDRESS <br />FACT NA <br />�ar�Vet Place <br />373-1166 ExT. <br />SITE ADDRESS 4405 <br />Street Number <br />I Diredio <br />Pacific <br />Avenue <br />Street Name <br />Stockton <br />Ci <br />95207 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />( 20? 478-5504 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Dulcinea Covan <br />COMMENTS: <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME Walton Engineering, Inc. <br />DATE: <br />Pfttg <br />373-1166 ExT. <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />Date Service Completed (if already completed): <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. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ <br />DATE: <br />OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 Compliance Manager <br />If APPLiCANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEA E MRMATION: 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE. <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />