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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 ), I" � <br /> OWNER / OPERATOR <br /> YRC Freight CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> YRC Freight <br /> SITE ADDRESS 1535 W Pescadero Avenue Tracy 95304 <br /> Street Number Direction Street Name Cit 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 # LAND USE APPLICATION # <br /> ( 913) 575- 9563 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Janelle Dockham CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Nwestco , LLC 661 631 -3870 <br /> HOME or MAILING ADDRESS FAx # <br /> 2209 Zeus Court ( 661 ) 587 -9758 <br /> c " Bakersfield STATE CA zIP 93308 <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 /> 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 .Ckc 7eclelLl DATE : 08 / 15/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Clerk <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 asse gy}� Ii P cation <br /> the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it I `` e or <br /> my representative . <br /> AMT <br /> TYPE OF SERVICE REQUESTED : f7 2022 <br /> COMMENTS : SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Remove old rubber penetrations , Prep walls for FRP Bravo retrofit fittings . Test all sun�P'sVEd'fYd " i <br /> repairs and submit passing test results to CUPA . <br /> ACCEPTED BY: ` • �- y� \ i EMPLOYEE # : DATE: } ' / / n a 2L <br /> ASSIGNED TO : V' „ ltG�t r , �� STV EMPLOYEE #: DATE : �`f� <br /> Date Service Completed (if already completed) : SERVICE CODE: lq 157e4a P I E: 1, <br /> Fee Amount : ' ( j l Amount Paid - Payment Date <br /> Payment Type `� Invoice # CWCT # 3 Received By: All I <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />