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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility - 7A 00 ) 11U� lO <br /> 95n� <br /> OWNER / OPERATOR <br /> H & S Energy CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> H & S Energy #3084 <br /> SITE ADDRESS <br /> 3940 N . Tracy Blvd , Tracy 95304 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) pq Yn n <br /> Street Number Street Name rYl NT <br /> CITY STATE ZIP LSD <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # C <br /> ( ) SAN J v X22 <br /> PHONE #2 EXT. BOSDISTRICTy'�NME gNTy <br /> ( ) EPA N ENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Walton En ineerin Inc . 916 373- 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 1025 ( 916 ) 373- 1172 <br /> CITY West Sacramento STATE CA ZIP 95691 <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 /> 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 : DATE : 11 /04/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / MANAGER OTHER AUTHORIZED AGENT 0 Construction 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 . <br /> TYPE OF SERVICE REQUESTED : �.S'r t_ <br /> COMMENTS :�� �, � <br /> ACCEPTED BY : \ i EMPLOYEE #: DATE : I 242 <br /> ASSIGNED TO : CA <br /> v EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed) : -- - SERVICE CODE: P � / E : <br /> Fee Amount:`' Amount Paid �� � Payment Date <br /> Payment Type � � Invoice # Check # 15277LO2. d Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />