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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OLD Market >� 22 <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> City of Tracy <br /> FACILDYNAME Westside Market <br /> SITEADDRESS ' <br /> 741 Street Number DI0�i r4 <br /> ton Centa>;(�ttem Tracy, <br /> HOME Or MAILING ADDRESS (If Different from Site Address) e IC�L9 <br /> 4263 N. Selland Ave. 6treetNumber feetNama t7 <br /> CITY STATE ZIP ENV qQV/ <br /> Fresno Calif. 93729) /? Cnt <br /> PHONE#1 EXT. fv <br /> APN # LAND USE APPLICATION # ' 17 �FpgRNffrl TgC <br /> ( 925,, L <br /> )y, 586-3317 cell 235-068-006 SEN <br /> PHONE# T• BOS DISTRICT LOCATE; DE <br /> ( 925) 684=4413 home 005 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKIf BILLING ADDRES <br /> Jack Cook Estimator/PM S <br /> BUSINESS NAME PHONE # a T. <br /> CVE Contracting Group Inc. dba Central Valley Environmental 925 586-3317 <br /> HOME or MAILING ADDRESS FAX# <br /> 4263 N. Selland Dr. ( 559) 222-1174 <br /> CITY Fresno, Ca. 93722 STATE zip <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C004 DATE,�.:, 02-07-18 <br /> PROPERTY / BUSINESS OWNER ❑ ERATOR / MANAGER 13OTHERAULYJ <br /> THOWEDAGENT Estimator/PM <br /> It APPLICANT Is not the BILLING PARTY. proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. C <br /> TYPEOFSERMCEREQUESTED: S <br /> COMMENTS: <br /> Pull and remove old 500 gal. tank from rear of parcel -Haul as Haz even though nothing present. 0 7 2018 <br /> ENVIRONMENTAL HL_ ' LTH <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (h already completed): SERVICEC00E: � 7J• PIE: a3epv i <br /> Fee Amount: 456.0,0 Amount Paid 456.00 Payment Date 02-07-18 6,21 <br /> Payment Type Card f5' Invoice # C ck # 007 &3 Received By: <br /> EHD 48-02,025 SR FORM (Golden Rod) <br /> 07117/06 <br />