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0 New F;;r.ility <br />It ExistIng Fad ity <br />1,l"4�( r <br />ar Joaquin Counter Environmental Health Department <br />Application Form <br />Fadlity Name <br />FedEx ground - Tracy <br />Site Address <br />c1tY <br />State <br />Zip <br />5655 Hood Wa <br />AddressZIP <br />942 S. Shady Grove Rd <br />A <br />95377 <br />APM <br />Supervisor District <br />Phone <br />Emall <br />804431 <br />Typeof 54-mbee. <br />❑ Applfcatlan For <br />❑ Consultatlan <br />❑ [Mingo of Owner <br />(4 Repairs nr Remodel <br />❑ Other <br />Aeque5tcd <br />Optsr-1ting Permit <br />509 213-5266 <br />Comments Replace llox aonneclor fn T1 and T2 El mer STY sump. <br />If mobile food truck or license Plate Nurnber <br />VIN <br />pumper Iruck <br />Contact Types Q mmng Party ❑ FacNlty Owner 13 1+ac414 Canuml 2 Ptoperty owner Contractor ❑ Arctdiecl <br />required <br />Q !!11141& Party IxFacility Owner <br />❑ Facillty contwA <br />Ix Pfopeny Owner <br />❑ Contractor ❑ Architect <br />First Name FedEx Freight Inc <br />Last dame <br />If COMM tOt, ltldlCxte type end ilrense mtrnber <br />AddressZIP <br />942 S. Shady Grove Rd <br />Clsmote <br />�mphis <br />TN <br />138120 <br />Phone <br />Phone <br />Emall <br />804431 <br />Address 9595 Lucas Ranch F'oad #900 <br />filing Party <br />❑ Facility Owner <br />❑ Facility Contact ❑ Prgpefty Chgner <br />jVQDtFjCt0f <br />❑ AFChlteC% <br />Feeb17 <br />1-761 <br />Record tum <br />5 i 4 <br />iE <br />0 Chedt <br />First Name <br />Albert <br />Last name <br />Barajas <br />If contractor. Indbeate type and IloerFse nu mbar <br />804431 <br />Address 9595 Lucas Ranch F'oad #900 <br />Coy <br />RaTr0hO GUCafTIOnga <br />SRate <br />CA <br />ZIP <br />91730 <br />P404t` <br />rslaa�ifpelro9roup <br />Phone �FL <br />509 213-5266 <br />61111ng Party 1 Q Fadlity Owner <br />Name <br />Address <br />Ph"e I Phone <br />FadlkyCentact <br />Last name <br />Emi14 <br />Q Property Owner 1 ❑ Contractor 1 ❑ Architect <br />IF mmra€torr. In lkate type and <br />cxy I State I 2tP <br />BILLING ACKWYMEd6EMEN Tr I, the undersigned property or business owner, operator or authorl?ed agent of carne, acknowledge t -rF <br />5pecif Ic ENVIRONMENTAL HEAITH DEPARTMENT hourly Charges associated with this protect or artlutty will be billed Rq me �r mw bu3Ln4Ss . , , "+L <br />FDrM, <br />I also CerLlry that I have prepared this appllcatipn and that the wafk to be pefformed will be done In -accordance with All SAN laAQUIN COUNTY Ordinance Codes, <br />SLandardsr STATE and FEOEW Saws. <br />APpucANTS SIGNATURE, ".;r- 3iao- nAT$F; 7125125 <br />M PROPERTY / BUSINESS OWNER Cl OK RATOR � MANAGE R ❑ 011-1!� fi AUtHORIZEQ AGENT M Assistant Environ menlal Compliance PM <br />Title <br />If APPLICANT is riot the BICLIN43 PARTY, Pfoaf of authorlsat6on to $IV is fequlred <br />AUTHORIZATION TO RELEASE INFORMATION.' When applkable,1, the owner at operator of the propetty located at the above site address, hereby authorize the <br />rerease of any and all results, geotech nkal data andcr enwlfonmentallsim assessment Infarmatlpn to the 5AN joAC uiN couNTf ENVIRONMENTAL HEALTH <br />DFPARTMkN7 as soon as It IC wail;kWeand at the same time it i, nrovlrlpd to me cpr mw roare&antatlwf, <br />11aepRee{ Ely <br />..3 (� ✓Va <br />AssISncd is ,f / <br />i !/l /� <br />Unked F I[} y j <br />oo:2-3y 60�j <br />Da V <br />PE00 <br />Feeb17 <br />1-761 <br />Record tum <br />5 i 4 <br />0Cpsh <br />0 Chedt <br />/ <br />CGollirmptiCal k f <br />Payment <br />Reci loved 9y <br />RNV i)V i 0}2024 <br />