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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUESTAl <br /> Type of Business or Property FACILITY ID# tERVICE REQ ST# <br /> Gas Station&C-Store <br /> OWNER 1 OPERATOR <br /> B&W Petroleum CHECK If BILLING ADDRESS. <br /> FACILITY NAME <br /> B&W Petroleum H&M-BVV#98 <br /> SITE ADDRESS <br /> 2501 Street NumW Dr w, JacksonEscalon 95320 <br /> Silreat Name city2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATEzip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( 209) 838-3971 <br /> f <br /> PHONE#2 fir• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICVkEQUESTOR <br /> REQUESTOR <br /> Nicholas Rowe CHECK If BILLING AD <br /> BUSINESS NAME PHONE# EXT. <br /> LC Services 559 892.5287 <br /> HOME or MAILING ADDRESS FAX# <br /> 3887 N Valentine Ave ( ) <br /> CITY Fresno STATE CA zip 93722 <br /> BILLING ACKNOWLEDGEMENT: I, the undersign property or business owner, operator or authorized agent. of same, <br /> acknowledge that all site and/or project specific ENVIRQNIvIENTAL HEALTH DEPARTMENT hourly charges associated with tris 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 DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:��h <br /> PROPERTY/BUSINESS OWNER[3 OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <br /> If APPLICANT is not the&&YI G PARTY,proof of Authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION;Whin applicable,1,the owner or operator of the property located at tlib <br /> above site address, hereby authoriz w the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN CO ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representativ . <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SEP 0 8 2017 <br /> ENVIRONMP: <br /> ACCEPTED BY: <br /> EMPLOYEE#: D _PAR <br /> TMENT TH <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Cmpieted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Tye Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />