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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> �1+1i003 9 co gs�d �i � <br /> OWNER / OPERATOR <br /> H &S Energy, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME H &S Energy 434 (Chevron) <br /> SITE ADDRESS <br /> 1434 VV Yosemite Ave Manteca 95337 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2860 N Santiago Blvd <br /> Street Number Street Name <br /> CITY Orange STATE CA ZIP 92867 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) (714) 448-5000 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> H &S Energy, LLC CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> H &S Energy #34 <br /> (714) 448-5000 <br /> HOME or MAILING ADDRESS FAX # <br /> 2860 N Santiago Blvd ( ) <br /> CITY Orange STATE CA ZIP 92867 <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 /> 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 : I/ lylado ¢ DATE : 9/27/22 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> 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 : a { A )?,(2,rlet <br /> COMMENTS : A <br /> SEP <br /> 29 <br /> NF N I//ON COO?Z <br /> TNDEpMENT,4� 7- )/ <br /> RTM <br /> ACCEPTED BY : EMPLOYEE # : DATE : z!� <br /> ASSIGNED TO : G rja t Al O EMPLOYEE # : DATE : I 'L <br /> Date Service Completed ( if already completed ) : SERVICE CODE : /� PIE : A <br /> Fee Amount:'' v- Amount Pai Payment Date <br /> Payment Type Invoice # Check # ,56,.zReceived By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />