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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gasoline Dispensing Facility fA 000 "j�F 3 <E�) DSQ <br /> OWNER / OPERATOR <br /> H & S Energy CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> H &S #3081 <br /> SITE ADDRESS <br /> Pacfic Ave Stockton 95207 <br /> 6633 Pacfic Ave Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, qpN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS INA PHONE PHONE # ExT. <br /> vvalton Engineering , Inc. 916 373- 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> PO Box 1025 ( ) <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 /> 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 : ) a4oe2Z c" 'r �tdi'P.u _ DATE : 02/02/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / aNAGER ❑ 04r OTHER AUTHORIZED AGENT 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 assessor nt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pr�j�,i;Q me Or <br /> my representative . rAiM <br /> TYPE OF SERVICE REQUESTED : KpjPk <br /> COMMENTS: (U J / tL O �uqN O <br /> V tiEEN 0R Qul 3 �?3 <br /> 0 COO <br /> NT <br /> ACCEPTED BY: i�� /a EMPLOYEE # : DATE: 12 <br /> 2 <br /> ASSIGNED TO : /Y J � ( 4 eq EMPLOYEE # : DATE: <br /> Date Service Completed if already completed ) : 6712 S 2 1� SERVICE CODE :/If -Agyl PIE : <br /> Fee Amoun . 46 Amount Paid l�(o 1 Payment Date�103 <br /> Payment Type �t Invoice # Check # 156 , 2 Received By : <br /> a POW Pew &Zhj <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />