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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# EXT' <br />SERVICE REQUEST # <br />FAX# <br />0o<DIP0oS-T <br />-1 cog (0012 <br />OWNER/ OPERATOR <br />CHECK if BILLINGADDRESSE] <br />H&S Energy Products, LLC <br />FACILITY NAME <br />ACCEPTED BY: <br />H&S Energy Products, LLC #3084 <br />EMPLOYEE M 1 <br />SITE ADDRESS <br />ASSIGNED TO: <br />{` <br />EMPLOYEE #: 1-15aCr1 <br />DATE: t t — :3 — 2 2 <br />Date Service Completed (if already completed): <br />3940 <br />SERVICE CODE: 0101 <br />I N. Tracy Blvd <br />1 PIE:' 1 b <br />Tracy <br />1 S ,<::, _ <br />d <br />Street Number <br />Direction <br />Street Name <br />C L <br />ca,95* <br />Bode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />2860 <br />N Santiago Blvd <br />Street Number <br />Street Name <br />CITY Orange <br />STATE <br />zipCA <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION <br /># <br />(714 )761-5426 <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK It BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT' <br />HOME or MAILING ADDRESS <br />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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: I- ".r DATE: 11/08/22 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Manager <br />IfAPPLtcANT is not the B1LLIA'G 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 atSame time it is <br />provided to me or my representative. A�. _ MAS._ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />I Wv 08411 <br />� <br />H "'700 <br />T'NFNT <br />ACCEPTED BY: <br />L �� <br />EMPLOYEE M 1 <br />DATE: \ 1 <br />ASSIGNED TO: <br />{` <br />EMPLOYEE #: 1-15aCr1 <br />DATE: t t — :3 — 2 2 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0101 <br />1 PIE:' 1 b <br />Fee Amount: <br />1 S ,<::, _ <br />Amount Paid <br />S b <br />Payment Date <br />Payment Type <br />C L <br />Invoice # <br />Check # �.5�(o D�/o7 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />614 b (to <br />SR FORM (Golden Rod) <br />S <br />