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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �FACILITY ID# SERVICE REQUEST# <br /> Gas Station VA D o1'0, m <br /> OWNER I OPERATOR <br /> Mike Popari CNFCK if BILLING ADDRESS❑ <br /> FACILITY NAME Vanco <br /> SITE ADDRESS 1033 W Charter Way Stockton 95206 <br /> Street Number Direction Street Name Citv ZIP.Code <br /> HOME or MAKING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE M fir. APN# LAND USE APPLICATION# <br /> ( 916) 3961665 <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK ifBlLUNGADDRESS <br /> ® <br /> BUSINESS NAMEEilte IV Contractors PHONE# ExT• <br /> 209 461-6337 <br /> IICsME Or MAILING ADDRESS2535 Wigwam ( 2 Dr Stockton Ca 95205 <br /> ( 209) 461-6342 <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: l eI q4 ltlWhgU DATE.- 8/11112;017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I NIANAGER 0 OTHER AUTHORIZED AGENT IX Office Assistant <br /> IfAPPLICRNr 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 to the SAN JOAQUIN COUNTY EN'VIRONMENT'AL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. r .,.. . <br /> TYPE OF SERVICE REQUESTED: JzFlgoF1 I <br /> COMMENTS: nC EFC AUG i 2011-f <br /> AUG 14 2U17 <br /> EWRo"iI�+C{?UN7'Y I � lY ` M `.iia 4 f' <br /> E M . . <br /> HEALTk f7 �47q� <br /> uAR1-VEry7 l'iP <br /> ACCEPTED BY: EMPLOYEE EMPLOYEE#: 6•��'] DATE:. <br /> ASSIGNED TO: e . � r ayrv4/ ,� EMPLOYEE#: V if DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1,9g P.I E: <br /> Fee Amoun �fS6 Amount Pai !}� Payment Date ��e?l <br /> Invoice# ReceivedBy-.Type 70 <br /> EHD 4B-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />