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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> OWNER/OPERATOR <br /> Mike Popari CHECK IfBILLING ADDRESS <br /> FACiurvNAME Vanco Truck Auto Plaza <br /> SITE ADDRESS 1033 W Charter Way Stockton 95206 <br /> Slreel Number 'recllon I 5 re Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> !reef Number Stroot Nerne <br /> CITY STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> ( 91 9 396-1665 1 r -J ✓UL, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors (20P)461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr (209)461-6342 <br /> CITY Stockton STATE Ca ZIP <br /> 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: Mom mite/'cew DATEF./ 11812018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El0-rima.AUTnouizEUAGENT[X Offirt- Assistant <br /> IfAPPLICAN'T is nol the BILLING PARTY proof of fnithorizarion to sign is required Title <br /> AUTI4QRIZATION TO RELEASE INFORMATION: When applicable,1,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 DEPARTMENTas soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: DEF Dispenser Replacement `p�p� �B <br /> COMMENTS: V, <br /> r. <br /> HFq�T7%�MEC0UN <br /> Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ �TMF <br /> lV <br /> ASSIGNED TO: C r C 0( EMPLOYEE#: DATE: t- 1 ' - <br /> Date Service Completed (If already completed): SERVICE CODE: I P IF: <br /> Fee Amount: Jb Amount Paid ��� v� Payment Date �l <br /> Payment Type ,!� _ Invoice# Ch k JI Received By: / <br /> EHD 40-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />