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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 A M 721 !! � <br /> OWNER / OPERATOR <br /> H & S Energy CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> H & S Energy #3081 <br /> SITE ADDRESS <br /> 6633 Pacfic Ave Stockton 95207 <br /> Street Number Direction Street Name Cit Zi 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 /> ( ) <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 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 : DATE : 02/06/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / MANAGER ❑ 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOVlded to me or <br /> my representative . P <br /> TYPE OF SERVICE REQUESTED : Us � ���} f NEC <br /> COMMENTS : <br /> FE8 <br /> / 2 2024 <br /> Sq NVIR p UIN COON T <br /> NEgLTy DEPARTMENT <br /> ACCEPTED BY : nh�- � � //Q �� , EMPLOYEE # : DATE : <br /> ASSIGNED TO : 'n`•-/7l v r_/�� ! `J EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : �- SERVICE CODE : �L P I E : �f 8 <br /> Fee Amount: D � Amount Pai LL91 Payment Date 2, <br /> v <br /> Payment Type t Invoice # Check # L760 0Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />