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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />GAS DISPENSING FACILITY <br />BUSINESS NAME <br />ASSIGNED TO: <br />OWNER / OPERATOR <br />WALTON ENGINEERING <br />7 -Eleven, Inc. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Fee Amount: <br />PACIFIC CAR WASH <br />PO BOX 1025 <br />SITE ADDRESS <br />( ) <br />4415 PACIFIC AVE. <br />STOCKTON 795z2i(07 <br />Street Number Direction <br />Street Name Cit Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PO Box 711 <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />Dallas <br />TX 75221 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 916) 742-0232 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REOUESTOR <br />REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propert <br />COIdMENTS6 <br />Sarah Jablonslc -Construction Mana er <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />ASSIGNED TO: <br />PHONE# EXT. <br />WALTON ENGINEERING <br />Date Service Completed (if already completed): <br />916 373-1165 <br />HOME Or MAILING ADDRESS <br />Fee Amount: <br />FAX # <br />PO BOX 1025 <br />Payment Type <br />( ) <br />CWEST <br />STATE ZIP <br />SACR MENTO <br />CA 95691 <br />y or business owner, operator or authorized agent of same, <br />acknowledge that all Site and/Or prOjeCt SpeCIfIC ENVIRONMENTAL HEALTH DEPARTMENT hoUfly Charges aSSOClated 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 perf <br />ormed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL 12WS. AA <br />APPLICANT'S SIGNATURE: ��-j k,N <br />`4nf��v' DATE: 04/7/21 <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ CONSTRUCTION MANAGER <br />If APPLICANT 10 <br />ITOf fhe BILLING PARTY plOOf Of aUfhO/iZaf%On f0 Slgn IS re4Ulred Tlite <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 />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 <br />my representative. <br />TYPE OF SERVICE REQUESTED; <br />COIdMENTS6 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I 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 />07/17/08 <br />