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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 >�f� �(.� ss` � � � � 00 2ka <br /> OWNER / OPERATOR <br /> H &S Energy CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> H&S Energy #3081 <br /> SITE ADDRESS <br /> 6633 Pacfic Ave Stockton 95207 <br /> 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. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky - Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Walton Engineering , Inc . <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 /> 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 : 45a4 DATE : 05/23/2023 <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 /> to 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 . PA �Xh <br /> TYPE OF SERVICE REQUESTED : G { I7 7 �] f RE T <br /> COMMENTS : <br /> JUN 2023 <br /> HEAL NSAN AONMENTL Y <br /> OEPARTMEN <br /> ACCEPTED BY : �� /\ EMPLOYEE #: DATE: �/5O 2 <br /> ASSIGNED TO : one ya e lit f EMPLOYEE # : DATE: i � <br /> Date Service Completed ( If already completed) : SERVICE CODE : gggL ll f PIE: ` <br /> Fee Amount: ro Amount Pa lo � Payment Date <br /> Payment Type // Invoice # Check # ,7 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />