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❑ New Facility Existing Facility <br /> NQi� S' S <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> H&S Energy #3084 <br /> Site Address City Tracy State ZIP <br /> 3940 N. Tracy Blvd. y CA 95304 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 0 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> Replace 87 Spill Contianer <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party 0 Facility Owner ❑ Facility Contact ❑ Property Owner 0 Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ontractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Walton Engineering, Inc AB Haz 617238 <br /> Address City State ZIP <br /> P.O. Box 1025 West Sacramento CA 95692 <br /> Phone Phone Email <br /> 916-373-1166 veronica.f@waltonE ngineering.com <br /> ❑ Billing Party 0 Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> H&S Energy <br /> Address City St ZIP <br /> 2860 N. Santiago Blvd Orange a&A 92867 <br /> Phone Phone Email <br /> 916-738-1818 m.lewis@hasoil.corn <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Archite A <br /> First Name Last name If contractor, indicate type and license / <br /> D <br /> Address City State ZIP 1912220 <br /> Phone Phone Email HFq�V/ROAM N T CD <br /> y <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project /VT <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> 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 COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws.r /�� � �� <br /> APPLICANT'S SIGNATURE: l/ DATE: 04/21/25 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Contractor <br /> Title <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the <br /> release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepte B Assig ed To Linked FA ID , <br /> sic /2&Q <br /> Date 27 PE_ J� O} Fee I Record Number 25 1 (9 a. (0 <br /> ❑ Cash ❑ Check# UD Confirmation# 2W3�'��'( I� Payment <br /> / i Received By <br /> Rev 07/10/2024 <br />