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SAN JOAQUIITCOUNTY ENVIRONMENTAL HEALTH ITEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# rr � �JSERVICE REQUEST# <br /> GDF ( U 3�' T S �� 4e-T02-(02 <br /> OWNER/OPERATOR Yellow Freight Lines CHECK M BILLING ADDRESS❑ <br /> FACILITY NAME Yellow Freight-Tracy <br /> $READDRESS 1535 Pescadero Ave Tracy 95304 <br /> Street Number I Direction I Street Name Clzip C s <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 E.. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 en. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson 303890 CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Testing-SST INC 209 465-5577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 1 (209 1 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <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 <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'-'s t--- "/�— DATE: 5/28/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O OTHER AUTHORIZED AGENT® President <br /> IJAPPLICANT is not the BILLING PARTY proof of authorization to sign Is required TI tie <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 Tame time It Is <br /> provided to me or my representative. �Q <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT C <br /> COMMENTS: Replaced ATG battery, coldstarted, restored from archive and checked operation. g 2, <br /> yFq N04Q <br /> HSE q"NTq,N <br /> T�FNT <br /> ACCEPTED BY: EMPLOYEE#: ' DATE: <br /> ASSIGNED TO: T' ;✓ EMPLOYEE#: � q-6 DATE: 70!/'IJa[ 13 <br /> Date Service Completed (if already completed): 5/24/13 SERVICE CODE: ! Y PIE: Zia <br /> Fee Amount: 3 Amount PalD� Payment Date <br /> Payment Type Invoice# Check# !/027 Recei d By:, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />