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SAN JOAQUI[V COUNTY ENVIRONMENTAL HEALTH MPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF r jK lvS�S 9 I <br /> OWNER I OPERATOR <br /> CHECK K BILLING ADDRESS <br /> FACILITY NAME Yellow Freight <br /> SITE ADDRESS 1535 Pescadero Ave Tracy 95304 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT L0CA noN CODE <br /> i 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Err. <br /> Service Station Testing -SST INC 209 465-5.577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 (209 } 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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: C�� - f - DATE: 8/28/12 <br /> PROPERTY L BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> If APPLIiCANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: LEE PAYMENT <br /> .1 REECEINIEn <br /> COMMENTS: Replaced 303 sensor at L-4 (T-1 annular) AUG 2 8 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ?� f. <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 8/27/12 1 <br /> SERVICE CODE: P I E 09 <br /> Fee Amount: Amount Paid Qb C) Payment Date <br /> Payment Type Invoice# Check# Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />