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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility FA-c0o ?�G1 6 Roo <br /> OWNER / OPERATOR <br /> H & S Energy CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> H &S Energy #3084 <br /> SITE ADDRESS <br /> 3DDR N . Tracy Blvd . FTracy [95 ,4304 <br /> Street Number Direction Street Name City i 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 . 916 373- 1165 <br /> HOME Or MAILING ADDRESS FAX # <br /> PO Box 1025 ( 916 ) 373- 1172 <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 : c'� & DATE : 04/ 19/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / MANAGER 6 OTHER AUTHORIZED AGENT 1Z 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 /> t0 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 . <br /> TYPE OF SERVICE REQUESTED : Uk S Rzlyo <br /> COMMENTS : <br /> ACCEPTED BY : �, EMPLOYEE # : DATE : <41 I <br /> :a CAA 2 <br /> ASSIGNED TO : 1G� ^ I O EMPLOYEE M n DATE : Z I at Z <br /> Date Service Completed ( if already Completed ) : SERVICE CODE : ` ? 2 � PIE : Z � � g <br /> Fee Amount : /� _ Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />