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u � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property /FACILITY ID# SERVICE REQUEESTT# <br /> GDF 3 D j EC06(139- <br /> OWNER/OPERATOR <br /> 1bC)OWNER/OPERATOR Yellow Freight CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Yellow Freight <br /> SITEADDRESS 1535 Pescadero Ave Tracy 95304 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE`.A ZIP <br /> PHONE#1 ETT' APN# LAND USE APPLICATION# <br /> ( 209 ) <br /> PHONE#2 al. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing-SST INC 209 465-5577 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 31465 1 (209 1 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <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 <br /> or 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,Smndarrd'+s,STATE and FFEEDws. <br /> APPLICANT'S SIGNATURE: C, ll�— N DATE: 2/15/12 <br /> PROPERTY/BUSINESSOWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT® President <br /> J,fAPPL/CANT is not the BILLING PARTY proof of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It Is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT R <br /> COMMENTS: Replaced defective WASTE OIL annular 303 sensor. FEB <br /> 16 2012 <br /> s"N JOAQU MEi� <br /> ROI <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: eY! 1 DATE:21116111 <br /> ASSIGNED TO: [A EMPLOYEE r4 DATE: <br /> Date Service Completed ( already completed): 2/15/12SERVICE CODE: PIE: <br /> Fee Amount: UU Amount Paid Payment Date (o a— <br /> Payment Type Invoice# Check# g'3� Received By: ;7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />