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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SE ICE REQUEST # <br /> Transportation Fueling Site FA0003854 S C 1191 � 0 <br /> OWNER OPERATOR �J` ' <br /> CHECK IfBILLING ADDRESS <br /> FACILITY NAME <br /> YRC, Inc. <br /> SITE ADDRESS E Pescadero Avenue racy 95304 <br /> 1535 Street Number Direction Street Name Citv 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. APN # j� LAND USE APPLICATION # <br /> ( 913 ) 575-9563 1 Q V <br /> PHONE #Z Exre I FIBIOSDISTIICT LOCATION CODE <br /> ) 03 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Janelle Dockham <br /> BUSINESS NAME PHONE # EXT. <br /> Confidence UST Services 661 631 -3870 <br /> HOME or MAILING ADDRESS FAx # 587-9758 <br /> 16250 Meacham Road ( 661 ) <br /> CITY STATE zip <br /> Bakersfield CA 93314 <br /> BILLING ACKNOWLEDGEMENT: 1, the und9 signed property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project Specific NVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as id ntified on this form . <br /> 1 also certify that I have prep d this applic Ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sta rds, STAT nd FEDERAL laws , <br /> APPLICANT'S SIGNATURE : DATE : 2/21 /2020 <br /> PROPERTY / BUSINESS OWNER ❑ ERATOR / MANAGER ❑ OTHER UTHORIZED AGENT ® Permit Clerk <br /> If APPLICANT Is not the ILLING PARTY. proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE i FORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize th release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENV[ NMENTAL HEALTH DEPAR ENT as soon as it is available and at the same time it is provided tome or <br /> my representative . PJ <br /> TYPE OF SERVICE REQUESTED : Re ve existing 4 "x96" tank riser and replace with shorter tank riser. Install CNI 214P Spill Cont I� i A <br /> COMMENTS: E6 <br /> s FEB 25 <br /> H gNORpV/AtCZO?0 <br /> cryo pgRev°�Nry, <br /> ACCEPTED BY: / EMPLOYEE #: DATE : ( n <br /> ASSIGNED TO : N , ` r vl J EMPLOYEE #: DATE AW <br /> Date Serv/(ce Completed ( if already completed) : 1 SERVICE CODE : PIE: <br /> Fee Amount: tib Amount Pai Payment Date zs <br /> Payment Type ,� Invoice # Check # �OS(p �2��i Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />