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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nSERVICE RIE JQUEST# <br /> Gas Station and Convenience Store 2-19 3 c.JK <br /> OWNER/OPERATOR <br /> H&S Energy Products, LLC. CHECK If BILLINGADDRESS� <br /> FACILITY NAME <br /> H&S Energy Products,LLC.#3081 <br /> SITE ADDRESS 6633 Pacific Ave. Stockton 95207 <br /> Street Number I Dlrecllon Street Name city ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2860 N.Santiago Blvd. <br /> Street Number Street; <br /> CITY Orange STATE ZIPCA 95207 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 714 ) 761-5426 AWA230 097-410-480 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> N/A CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 JOAQUHN <br /> COUNTY Ordinance Codes,Standards,STATE and FE a la <br /> APPLICANT'S SIGNATURE: DATE. 01/07/2022 <br /> PROPERTY/BusiNESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Compliance Manager <br /> IfAPP7tc,4 T is not the BicciNG PAR 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JoAQufN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. LA YM p ii F <br /> ,TtFTYPE OF SERVICE REQUESTED: f'(tan 0 a ,.,�,�� CE/yr <br /> COMMENTS: <br /> AN 2o 2027 <br /> SA'V JOA Qlj <br /> MEIN COUIV <br /> L H DTy <br /> EPARTMENT <br /> ACCEPTED BY: (,vtS �-6 EMPLOYEE DATE: ZL) ._ ZZ <br /> ASSIGNED TO: H EMPLOYEE M DATE: I ,.z D <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> jCo <br /> Fee Amount: (S Z Amount Paid - Payment Date <br /> Payment Type Invoice# Check# /3 S�o�/! Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 rPA 1' 026-L <br />