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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 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRES <br /> Colonial Ene LLC <br /> FACILITY NAME <br /> Hassan and Sons Ener-q Products LLC <br /> SITE ADDRESS <br /> 192 Street Number Direction iLathropRbad 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 /> 71 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ft <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 STATE3A 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 pfirformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL I s . <br /> APPLICANT'S SIGNATURE : Beckv Galle O DATE : 2/15/21 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 1Z 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, 1 , the owner or operator of th2pjVetty located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or enviro a al/ to assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and time it is provided to me or <br /> my representative. �A <br /> TYPE OF SERVICE REQUESTED : t� <br /> COMMENTS : <br /> X <br /> O P <br /> ACCEPTED BY : EMPLOYEE M !.� DATE : <br /> ASSIGNED TO : EMPLOYEE #: V DATE: <br /> Date Service Completed (if already completed) : SERwcECODE : PIE : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />