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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> (Aff��� � 1 � SROO '87755 <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: �a—lme , �.� 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: U <br /> COMMENTS: f-DY ..Q� �� \�y,� r� � � �e 22 <br /> V10� GIfi�=�'1k21 c� ISS A�Ty <br /> ��1q �23 yE NVRoO,N COO <br /> Nt <br /> N <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> ASSIGNED TO: / ) per} EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ���1�� P I E: 0� <br /> Fee Amount:-: V,W t� e F Amount Paid �-�� -f- ��b Payment Date <br /> Payment Type '� Invoice # Check # 4 Lr7 Received By: <br /> elm <br /> EHD 48-02-025 a� I ; „ ^ ' SR FORM (Golden Rod) <br /> 07/17/08 L,J �J <br />