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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GDF TAGGGO ? 5LI S Go 11� � Lin <br /> OWNER / OPERATOR <br /> YRC # 813 (Tracy) CHECK if BILLING ADDRESS <br /> FACILITY NAME YRC # 813 (Tracy) <br /> SITE ADDRESS 1535 E Pescadero Avenue Tracy 95304 <br /> Street Number Dire tion 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 #') EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Janelle Dockham CHECK ffBILLING ADDRESS ® <br /> BUSINESS NAME Nwestco LLC PHONE # 1013 <br /> 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 /> 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 : D��.t� DATE: 12/ 10/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Clerk <br /> /f APPLICANT is not the BILLING PARTY, proof of authorfzatlon to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1, 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 environmentaVsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: Replace the T6 Drop Tube <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> ASSIGNED TO : EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: P 1 E: <br /> Fee Amount : Amount Paid Payment Date <br /> Payment TypeInvoice # Check # Received By: <br /> EHD 48m02-025 SR FORM (Golden Rod ) <br /> 07/17/06 <br />