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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CONTRACTOR /SERVICE R]IT FACILITY IID # CHECK If BILLING ADDRESS SERVICE REQUEST # GAS DISPENSING FACILITY BUSINESS NAME PHONE# EXT, WALTON ENGINEERING OWNER / OPERATOR HOME or MAILING ADDRESS FAX# PO BOX 1025 ( ) CITY CHECK If BILLING ADDRESS 7 -Eleven, Inc. CA 95691 ! SAE JOAQUIN C I' HEq Q T Y pE FACILITY NAME L TH AE�NOT ACCEPTED BY: V�� PACIFIC CAR WASH EMPLOYEE#: DATE: ASSIGNED TO: } /�� SITE ADDRESS EMPLOYEE #: DATE: j/j '�� off -1V PACIFIC AVE. completed): SERVICE STOCKTON /G7 ( j 95207 Code Street Number Direction 04 Street Name Payment Date City Zip HOME or MAILING ADDRESS (If Different from Site Address) Payment Type Invoice # PO Box 711 Received By: Street Number Street Name CITY STATE ZIP Dallas TX 75221 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 916) 742-0232 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE QUESTOR REQUESTOR S` - CHECK If BILLING ADDRESS Sarah Jablonsk -Construction Manager BUSINESS NAME PHONE# EXT, WALTON ENGINEERING 916 373-1165 HOME or MAILING ADDRESS FAX# PO BOX 1025 ( ) CITY STATE ZIP WEST SACRAMENTO CA 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project speCI11C ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 04/7/21 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT CONSTRUCTION MANAGER If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to me Or my representative. ( ^ _ - TYPE OF SERVICE REQUESTED: S` - EN T COMMENTS: ,) APR 14 2021 ! SAE JOAQUIN C I' HEq Q T Y pE L TH AE�NOT ACCEPTED BY: V�� EMPLOYEE#: DATE: ASSIGNED TO: } /�� F EMPLOYEE #: DATE: Date Service Completed loalready completed): SERVICE CODE: 230 6�PIE: /G7 ( j Fee Amount: %Pq.b�. ate% Amount Pai 04 Payment Date Payment Type Invoice # Check # S 2 Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08