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SAN JOAQI-S/COUNTY ENVIRONMENTAL HEALTIIMOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF ' Stf �� txJ (p y 6 SZ <br /> OWNER/OPERATOR Yellow Freight 9 CHECK If BILLING ADDRESS <br /> FACILITY NAME Yellow Freight-Tracy <br /> SITEADDRESS 1535 Pescadero Ave Tracy 95304 <br /> Street Number I Direction I Street Name c,ty Zip Code <br /> Address)HOME Or MAILING ADDRESS (If Different from Site Add <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Service Station Testing-SST INC/CSLB 962520 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 1 (209 ) 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 forth. <br /> I 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--�o r �./ DATE: 12/11/13 <br /> PROPERTY/BUSINESSOWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT® President <br /> IJfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envimnmentaUsite 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Replaced L-3 sensor(Waste Oil sump)at T-1. RECEIVEn <br /> DEC 112013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMIENTAL <br /> ACCEPTED BY: EMPLOYEE#: IO T/ DATE: /2/1/ 13 <br /> ASSIGNED TO: T��f-,J t EMPLOYEE#: 2&,Ie, DATE: /Z/ll <br /> 7 i <br /> Date Service Completed (if already completed): 12/10/13 SERVICE CODE: 9 fl PIE: ,.30j" <br /> Fee Amount: Amount Paid _ Payment Daae `a, 11 1.3 <br /> Payment Type ,/ / Invoice# Check# <br /> �j Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />