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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Car Wash / Gas Station � 000 <S / c,, �) qJ (.Pq <br /> OWNER / OPERATOR <br /> Chris Buscaglia CHECK If BILLING ADDRESS <br /> FACILITY NAME Zoom Car Wash <br /> Stockton 95212 <br /> SITE ADDRESS 3434 E . Hammer Lane <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) 209-9564040 <br /> PHONE #2 ExT. r <br /> ISTRICT LOCATION CODE <br /> ( ) <br /> (CONTRACTOR SERVICE Rrui QlUES'T OR <br /> REQUESTOR CHECK if BILLING ADDRESSL _ Il <br /> BUSINESS NAMEAIIOrda -Test PHONE # 209 -744 -0112 ExT <br /> HOME or MAILING ADDRESS 2nd Street FAX # <br /> ( ) <br /> CITYGalt STATE CA ZIP 95632 <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 t e work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F RAL laws . <br /> APPLICANT 'S SIGNATURE : DATE ; 11 /02/2021 <br /> PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER OTHER AUTHORIZED AGENT ❑ GMNP <br /> If APPLICANT is not the BILLING PARTY, pro of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 . P <br /> OF <br /> TYPE OF SERVICE REQUESTED : �c <br /> COMMENTS; Nov <br /> SAA1 ,/0 10 <br /> ® ��21 <br /> QUI <br /> NE7 <br /> A N�Ep E TTAN / y <br /> MENT <br /> ACCEPTED BY : (t EMPLOYEE #: DATE: �� Zf <br /> ASSIGNED TO : ('se �) �O/ �L�LJ EMPLOYEE #: DATE; P <br /> Date Service Completed (if already completed) : SERVICE CODE: ��� _�� P / E: Z / � <br /> Fee Amount : c / ��(P Amount Paidrer Payment Date �� 6 <br /> Payment Type Invoice # Check # J 2 S5 Received By <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />