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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 +e. t960.172� M 11117vs9 S Roo � 33 <br /> OWNER / OPERATOR H & S Energy CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME H & S Energy # 3035 <br /> SITE ADDRESS 192 Lathrop Rd . Lathrop CA <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 2860 N . Santiago Blvd . <br /> Street Number Street Name <br /> CITY STATE CA ZIP 92867 <br /> Orange <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> �71 <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Walton Engineering , Inc P16 373- 1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . 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 : DATE : 1 / 17/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Contractor <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 t0 me Or <br /> my representative . AOA <br /> /(/) <br /> TYPE OF SERVICE REQUESTED : Q ' •� <br /> COMMENTS : D <br /> sq JAN , 7 <br /> N JO ZO 4 <br /> NEq�TH�4 MV COU Ty <br /> RT C <br /> ACCEPTED BY: � EMPLOYEE # : ® 0 DATE: f T <br /> ASSIGNED TO : 44EMPLOYEE #: DATE: g <br /> i - � 11rr 11 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : 0 <br /> Fee Amount: Amount Paid $ L/LGsC`� Payment Date t Z <br /> Payment Type Invoice # Check # I7S0, Lot $ 2 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />