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SAN JOAQUIOW60UNTY ENVIRONMENTAL HEALTHWPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Transportation (Commercial) 'L)�� S'n Oo 3-7;�-�- <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> Yellow Transportation, Inc <br /> FACILITY NAME <br /> Yellow Transportation - TCY <br /> SITE ADDRESS ��`` <br /> 1535 Street Number DTn CH.. Pescadero AV treat Name Tracy CI 95304 oee <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVeal Number Street Name <br /> CITY STATE ZIP <br /> Same <br /> PHONE#t Ex. APN# LAND USE APPLICATION# <br /> ( 209 ) 833-1573 <br /> PHONE#2 Ev. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Michael Sills <br /> BUSINESS NAMEPHONE# Ex E . <br /> Professional Service Industries 562 597-3977 211 <br /> HOME or MAILING ADDRESS FAX# <br /> 3960 Gilman Street 1 (562 ) 597-8459 <br /> CITY Loong Beach STATE Ca ZIP 90815 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Project Manager Contractor <br /> 1fAPPL1C4NT is not the B1LLING 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 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. <br /> TYPE OF SERVICE REQUESTED: UST Retrofit and SB 989 Testing pAYMEN <br /> COMMENTS: <br /> MAR 19 2004 <br /> SA ENVIRONINE O AEN <br /> EALTH DEYARTM <br /> APPROVED BY: EMPLOYEE#: DATE: 6 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 6 <br /> Date Service Completed (if already completed): SERVICE CODE: Lqcy1 E.Z30g <br /> Fee Amount: 69-1)1- 0-0 Amount Paid $ 117. e-D Payment Date 3 ( Cl(o l( <br /> Payment Type ✓ Invoice# Check# L D 7 LR-L— Received By: LGA <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />