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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> ,'SVG �Ito SROVS7755 <br /> OWNER / OPERATOR <br /> Boyett Petroleum CHECK If BILLING ADDRESS <br /> FACILITY NAME H & M - BW #98 <br /> SITE ADDRESS 2501 Jackson Ave Escalon 95320 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 601 McHenry Ave <br /> Street Number Street Name <br /> CITY Modesto STATE CA ZIP 95350 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) 209 - 577 -6000 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR <br /> James Otto CHECK If BILLING ADDRES <br /> BUSINESS NAME LC Services PHONE # EXT , <br /> 559 -444 - 1730 <br /> HOME or MAILING ADDRESS 3887 N Valentine Ave FAx # <br /> ( ) <br /> CITY Fresno STATE CA ZIP 93722 <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 : �Glme.:y �o DATE : 2/ 15/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 Project Coordinator <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 . P <br /> TYPE OF SERVICE REQUESTED : ` ` C N <br /> COMMENTS : A p \ �y,� <br /> VI C) ct+ y') X21 �- ISS I � 1 q � 23 tiE NV Ro O/Al X24 <br /> A � TyDFpq�COO <br /> Nt <br /> N <br /> ACCEPTED BY : SIP /v EMPLOYEE # : DATE : <br /> ASSIGNED TO : / ) per} EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed ) : SERVICE CODE : �� ;O1lf P I E '3 p f' <br /> Fee Amount:: t I6 1�i Amount Paid �-�� -f- ��b Payment Date <br /> Payment Type V '� Invoice # Check # L�. Received By : <br /> f� b b t� em it ' <br /> EHD 48-02-025a� I ; „ ^ ' SR FORM (Golden Rod) <br /> 07/ 17/08 L,J �J <br />