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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility FA Cco ? (ZO0 Z 79 'j 2� <br /> OWNER / OPERATOR <br /> H & S Energy CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> H & S Energy #3084 <br /> SITE ADDRESS <br /> 3940 N . Tracy Blvd . Tracy 95304 <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 /> ( ) ala - :7( 0 - 0 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) o0 5 C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT , <br /> Walton Engineering , Inc . 916 373 - 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 1025 ( 916 ) 373- 1172 <br /> CITY West Sacramento STATE CA ZIP 95691 <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 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 : C:3a-1 DATE : 04/ 19/2024 <br /> Ir <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / MANAGER OTHER AUTHORIZED AGENT Construction Manager <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 . PA Ytiq <br /> TYPE OF SERVICE REQUESTED : S CCE <br /> COMMENTS : <br /> APR 19 2024 <br /> SAN JOAQUIN COUNTY <br /> HEALTH pE IN <br /> ACCEPTED BY : \ EMPLOYEE # : DATE : e4 Iq <br /> 2 <br /> ASSIGNED TO : � l % /� / VO EMPLOYEE # : DATE : G { I 0 Z <br /> Date Service Completed ( if already completed) : SERVICE CODE : / CI' ( : 2G19� ' P I E : 2 ?DO <br /> Fee Amount : q C( �& Amount Paid c� PaymentDate ' 11q12 <br /> Payment Type C Invoice # Check # 15Z Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />