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SAN JOAQ GO TY ENVIRENTAL HEALTH DEPARTMENT <br /> MI. <br /> SERVICUEST <br /> Type of Business or Properly F ILITY ID # SERVICE REQUEST # . <br /> OLD MarketCLW <br /> OWNER / OPERATOR MAR o t N16 <br /> CHECK If BILLING ADDRESS <br /> City of Tracy <br /> FACIUIY NAME <br /> Westside Ma etpNV1F10NMENTAL 1 <br /> SITEADDRESS t,� I'.} TAVI 1 <br /> 741 street Number Otrntlon Centelhrytw Tracy, <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ` e <br /> 4263 N. Selland Ave, Street Number so-eetName 41 g <br /> CITY STATE 7'n <br /> Fresno 0 <br /> PHONE#1 E• APN # <br /> ( 925) 586-3317 cell 235-068-006 ' �ENp <br /> PHONE#2 Exi. )DE <br /> ( 925) 684=4413 home <br /> CONTRACTOR / SER I <br /> REQUESTOR <br /> Jack Cook Estimator/PM ess� <br /> BUSINESS NAME <br /> CVE Contmoting Group Ino, dba Central Valley Environmental Sfi <br /> HOME Or MAILING ADDRESS T <br /> 4263 N. Selland Dr. <br /> CRY Fresno, Ca. 93722 <br /> FULLING ACKNOWLEDGEMENT: It the undersigned property f same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HE/ roject or <br /> 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 ti SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STTAnATE and//FEEn/n��ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 02-07-18 <br /> PROPERTY I BUSINESS OWNEREI ERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT EstimatOr/PM <br /> If APPL(cANr Is not the BILLING PAR proof of authorization to sign Is required Ttfte <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is provided to me or <br /> my representative. ; !' rl f `i r <br /> i i l _.; • H ,lr 1:�:;^a :'. :} iter. s**: ..1sc/ <br /> TYPE OF SERVICE REQUESTED: S J •' L+ : <br /> -- <br /> COMMENTS: <br /> Pull and remove old 500 gal, tank from rear of parcel -Haul as Haz even though nothing pre&FR. 0 e1 2018 <br /> t=ltl�/I1"Ii.✓�{�If�ei�Y`�j..�AL H"j %A. ;!�j,_§ <br /> a . 1;'}4vn� fi';?'�'Siil."1\II•� <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> ASSIGNED TO: EMPLOYEEM DATE: �Q <br /> Date Service Completed ( f alreadyeompleted): SERVICECODE: � ?� Pin: d004 <br /> Fee Amount: 456,00E Amount Paid 456.00 Payment Date 02-07-18 <br /> Payment Type Card y/5� Invoice 4A C ck # 007W3 Received By: <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> 07/17/08 In <br />