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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIL Y D # SERVICE REQUEST # <br /> GasolineDispensing Facility <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> YRC # 813 Trac <br /> FACILITY NAME YRC # 813 (Tracy) <br /> SITE ADDRESS Tracy E T 95304 <br /> 1535 1535 E . Pescadero Avenue y <br /> Street Number Direction I 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 91 Err. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• 130S DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Janette Dockham CHECK If BILLING ADDRESS ® <br /> BUSINESS NAMEPHONE # EM' <br /> Confidence UST Services 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 /> 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 law/S ./ <br /> APPLICANT' S SIGNATURE : C d4f a'& '? DATE : 11 /24/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT [R] 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It is pr��Cl to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : G V A4 <br /> ` OV <br /> ti q t// u/N 202, <br /> Tyo cpq�MENr <br /> ACCEPTED BY: EMPLOYEE M DATE: �9 <br /> ASSIGNED TO : • /J r ) rf EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : L�� PIE 2� 09 <br /> Fee Amount: Amount Paid , /P-aymgent Date � � 2Lf;? <br /> Payment Type �Sw Invoice # Check # 13S1TJ G8s Received By : <br /> /3524o 6 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />