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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # , SE VICE REQUEST # Fleet Vehicle Fueling Facility Q02-- W 5 OWNER / OPERATOR FedEx Ground CHECK if BILLING ADDRESSO FACILITY NAME FedEx Ground - Tracy SITE ADDRESS 5655 Hood Way Tracy 95377 Street Number Direction Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address ) Keep mailing address currently on file Street Number Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # ( ) PHONE #2 ExT, BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Rob Sills - Jones Covey Group , Inc . CHECK If BILLING ADDRESS BUSINESS NAMEPHONE # EXT, Jones Covey Group , Inc . 714 975 - 4257 HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # ( 909 ) 484- 0300 CITY Rancho Cucamonga STATE CA ZIP 91730 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes , Standards, STATE and FEDERAL laws . APPLICANT'S SIGNATURE : f�,pPeit DATE : 8/4/2023 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided KiYAWNT my representative . RECEIVED TYPE OF SERVICE REQUESTED : UST R4 11V In`I "� AUG 1 t 2023 COMMENTS : SAN JOAQUIN CC UNTY ENVIRONMEN AL T-3 Biodiesel Tank - Fill - Replace fill spill bucket like for like , PN : P711 - EVRDV ( OPW) HEALTH DEPART AENT to meet 5gallon minimum , per Inspection Notice 6/20/23 ACCEPTED BY : jy p C ive� �/7 , EMPLOYEE # : DATE: t o� ASSIGNED TO : �Vf4 l �� tel'/ EMPLOYEE # : DATE: Date Service Completed ( if already completed ) : w, SERVICE CODE : jqji . 2qLf 61E ,,12 Fee Amount : ov Amount Paid Payment Date Gp Payment Type V C � — Invoice # ck # Z (Ow�+ ?v Received By : EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08