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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station L) v3q/0 sQ0t 9 MOS <br /> OWNER / OPERATOR B &W <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME B &W # 98 H & M Food and Liquor <br /> SITE ADDRESS 2501 Jackson Ave Escalon 95320 <br /> Street Number Direction Street Name City Zip 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 ) 577-6000 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR James Otto <br /> CHECK If BILLING ADDRESS <br /> ��;K <br /> BUSINESS NAMELC Services PHONE # ExT. <br /> 559 444- 1730 <br /> HOME or MAILING ADDRESS FAX # <br /> 3887 N Valentine Ave ( ) <br /> CITY Fresno STATE CA ZIP 93722 <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 JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : James Otto DATE : 2/ 18 /2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . p <br /> TYPE OF SERVICE REQUESTED : U S 7� Rom mN <br /> COMMENTS : OF <br /> / 'eq <br /> O <br /> Sq <br /> '? 2022 <br /> HF N oRoN/N co <br /> NDEPgR�q /V I')' <br /> ACCEPTED BY : EMPLOYEE # : DATE : ;2� <br /> ASSIGNED TO : SEMPLOYEE #: DATE : 2i&�7L <br /> Date Service Completed ( if already completed) : SERVICE CODE : P 1 E � 00 <br /> Fee Amount: �H ��� c' Amount Pal `fz.� Ti� Payment Date 1 Z 2Z <br /> Payment Type _ Invoice # Check # JJ cj / l q 6 Received By : <br /> EHD 48-02-025 / SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />