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0 ! <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station &C- Store r t 5 <br /> OWNER 1 OPERATOR <br /> B&W Petroleum CHECK If BILLING ADDRESS 0. <br /> FACILITY NAME <br /> B&W Petroieum H&M-Bw#98 <br /> SITE ADDRESS <br /> 2501Escalon 95320 <br /> Streit Number Direction Jackson t eet Nam <br /> citi Code <br /> HOME or MARINO ADDRESS (if Different from Site Address) <br /> Street Number 51reet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 838-3971 (y t <br /> HONE#2 Err. BOS DISTRICT LOCA-n N CODE <br /> LA <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Nicholas Rowe CHECKIf BILLINGADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> LC SerAms 559 882-5287 <br /> HOME or MAILING ADDRESS FAx# <br /> 3887 N Valentine Ave ( ) <br /> CITY Fresno <br /> 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,ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /Il��f 7 <br /> s— – <br /> PROPEwry/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTIioRiz.EDAGENT M Contractor <br /> If APPLICANT is not the BILLING PARTY.proof of authotlzatlon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the property located at thb <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 av la an 1%sair" 13. <br /> pi ided to me or my representative. , <br /> TYPE Of SERVICE REQUESTED: PAYME <br /> N <br /> COMMENTS: /k".t^ r •' <br /> SEP 2 <br /> 0 2017 <br /> &A'hJCA��''^Z4 n7t4 <br /> ENVIRONMENTAL HEALTH <br /> H °E aRrE DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: I <br /> ASSIGNED TO: EMPLOYEE M DATE: �- <br /> Date Service Completed. (if already completed): SERVICE CODE: _ P I E: <br /> NA <br /> Fee Amount: 570Amount Paid Payment Date �j <br /> Payment Type �6,A Invoice# Ch # ��`j2 Recei ed By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />