Laserfiche WebLink
• t <br /> SAN JOAQt,,,, COUNTY ENVIRONMENTAL HEALT,. EPARTME.NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Truck and Auto Plaza ` CtZ )-15 (o a ci <br /> OWNER/OPERATOR ,�� <br /> Mike FlelpeA �QU�-�J�a1�.W` CHECK If BILLING ADDRESS <br /> FACILITY NAME Vanco Truck and Auto Plaza <br /> SITE ADDRESS 1033W Charter Way Stockton 95206 <br /> Street Number Direction lilreet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t Ext. APN# LAND USE APPLICATION M <br /> (916 ) -369-1665 D 4 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell <br /> "� CHECK IT BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# Ext. <br /> 20 461-6337 <br /> HOME Or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> ( ) <br /> CITY Stockton STATE Ca Zip 95205 <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: 2ff0adL fQ DATE: 8/25/2016 <br /> PROPERTY/BUSINESS OWNERD OPERA&/MANAGER ❑ OTuERAuTHNitiuDAGENT Q{ flffiWASsJsWnt <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 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: #11/12, #8/9(sat), #9/10, #14(sat) Failed SB989 Test <br /> COMMENTS: UST dTD PAYMENT <br /> RECEIVED <br /> AUG'2 9 2016 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: rl. EMPLOYEE <br /> ASSIGNED TO: �1 EMPLOYEE#: DATE: d <br /> Date Service Completed (if already completed): SERVICE CODE: /19S PIE: a $' <br /> Fee Amount: I — Amount Paid y 17• Payment Date $. Z 5- �6 <br /> Payment Type G`L Invoice# Check# 'g f7 C.t J Received By: <br /> REVISED 11/17/2003 EHD 48-02-025 SR FORM olden Rod) <br />