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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Transportation Fueling Site FA0003854 S1 001 / <br /> OWNER / OPERATOR VW� 00 <br /> CHECK if BILLING ADDRESS <br /> S <br /> Richard <br /> FACILITY NAME <br /> YRC , Inc. <br /> SITE ADDRESS E Pescadero Avenue Tracy 95304 <br /> 1535 Street Number 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 Zip <br /> PHONE #'1 EXT, AP <br /> # LAND USE APPLICATION # <br /> ( 209 ) 833- 1408 21306026 <br /> PHONE #2 ExT. BOS DISTRICT FO3 <br /> CATION CODE <br /> ( ) 005 �7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Karli Karns <br /> BUSINESS NAME PHONE # EXT, <br /> 16250 Meacham Road 661 631 -3870 <br /> HOME or MAILING ADDRESS FAX # <br /> 587-9758 <br /> 16250 Meacham Rd ( 661 ) <br /> CITY STATE ZIP <br /> Bakersfield CA 93314 <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 <br /> ��FEDERAL laws, <br /> APPLICANT' S SIGNATURE : /1Cl/LG'!� /1GhILd DATE : 03/27/2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Q Dispatch , Confidence UST Services <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 t0 me or <br /> my representative . <br /> PA rr <br /> TYPE OF SERVICE REQUESTED : Modification permit for replacement of (T6) L14 Veeder-Root sump sensor (MN 794380-208) on 02/18/20RPA <br /> COMMENTS : 4 ) <br /> Double permit fee provided for penalty fee . AP <br /> 2 ZO <br /> g8ANAfVl& IN COU <br /> FIFTH p p F?�k N <br /> ACCEPTED BY : F" � 2 ^ EMPLOYEE # : � ' DATE : ' � r <br /> ASSIGNED TO : � l V�' 1 tel?, EMPLOYEE # : DATE: Lf1�2) -020 t '� <br /> Date Service Completed (if already completed ) : SERVICE CODE : PIE : a3 oB <br /> Fee Amount: 1 "2 Amount Paid ���, D-D Payment Date <br /> Payment Type �/` Invoice # Check # �S��s Receiv d By : <br /> EHD 48-02-025 C004 [ e SR FORM (Golden Rod) <br /> 07/17/08 <br />�I <br />