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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH .) EPARTME f <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel Station � �C� � �7 D 51 N ?SS r7`0 <br /> OWNER / OPERATOR <br /> Sammy Orlando CHECK If BILLING ADDRESS ® <br /> FACILITY NAME Big Boy Chevron <br /> SITE ADDRESS 2226 Jackson Ave <br /> Escalon 95320 <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 /> ( 916) 708 -4999 227 -270 - 16 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sammy Orlando CHECK If BILLING ADDRESS ❑ <br /> BUSINESS NAME PHONE # EXT. <br /> Big Boy Chevron 916 708 -4999 <br /> HOME or MAILING ADDRESS 2260 Jackson Ave FAX # <br /> ( ) <br /> CITY Escalon STATE CA ZIP 95320 <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 ident' ' on this form . <br /> 000 <br /> I also certify that I have prepared this applica i; <br /> n a d kI t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards , STA nd F laws . <br /> APPLICANT' S SIGNATURE : DATE : 5 - 10 -22 <br /> PROPERTY / BUSINESS OWNER ® OPkaP.TdkTMANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 tlmI provided to me or <br /> my representative . Y I <br /> TYPE OF SERVICE REQUESTED : F <br /> COMMENTS : July <br /> &)N/�O 0/N c �0�? <br /> CTND pNt��0- y <br /> ACCEPTED BY : / ^� t EMPLOYEE # : DATE : <br /> ASSIGNED TO : V(�/, oeoq y "e�l EMPLOYEE # : DATE : lh / Z 2 <br /> Date Service Completed ( if already completed ) : SERVICECODE : le!? L — 2q? 113 / E : 2 ?n ;: <br /> Fee Amount: y � 2 O a Amount Paid <# 3112.0@ Urj Payment Date 7 cf Z2� <br /> Payment Type Invoice # Check # � Received By : <br /> EHD 48 -02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />