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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station � S2Ur C <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Colonial EneqrV LLC <br /> FACILITY NAME <br /> Hassan and Sons EnerProducts LLC <br /> SITE ADDRESS <br /> 192 Street Number Direction Lathrop Road Street Name Lathrop city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 2860 Street Number Santiago Blvd Street Name <br /> CITY STATE ZIP <br /> Orange CA 92867 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 714 ) 761 -5426 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Becky Gallego CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Fueling and Services Technology Inc. 657 262-8195 <br /> HOME or MAILING ADDRESS FAX # <br /> 7050 Village Dr Suite D ( ) <br /> CITY Buena Park STATFCA ZIP 90621 <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 /> 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 : Becky Gallego DATE : 2/ 15/21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permitting 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 /> t0 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 . �� �, „ G10 A <br /> TYPE OF SERVICE REQUESTED : os T l '�/ I U of t <br /> COMMENTS : V <br /> Ai <br /> sAN AFB 23 24?, <br /> �iHFALTHO NM, Ntv <br /> PgRr,• a � <br /> ACCEPTED BY : e (?� — EMPLOYEE # : DATE : <br /> ASSIGNED T0597i pEMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed : �— SERVICE CODE : / P 1 E : �� � <br /> Fee Amount : I f C5 D Amount Pal Payment Date 3 <br /> Payment Type '� � Invoice # Check # Z Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />