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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 &� ' �dr�✓ <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 City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #"I 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 ft ExT• <br /> Nwestco , LLC 661 631 -3870 <br /> HOME or MAILING ADDRESS FAX # <br /> 2209 Zeus Court ( 661 ) 587 -9758 <br /> CITY 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 SIGNATUREC��Zo¢& !/6C/leDATE : 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 f tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It I CCC Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : 2022, <br /> COMMENTS : SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Remove old rubber penetrations , Prep walls for FRP Bravo retrofit fittings . Test all SUN 'W'A tr " <br /> repairs and submit passing test results to CUPA . <br /> ACCEPTED BY : Sta <br /> t EMPLOYEE # : DATE: <br /> ASSIGNED TO : i It 9 EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : :;�7l�� PIE: •2 50 <br /> Fee Amount: ' Amount Paid Payment Date <br /> Payment Type '� Invoice # cfi c # l 3 5�s ' Received By: <br /> gl � s� � zL- <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />