Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APR 19 2016 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REf,1lj <br /> Truck Stop 38 Z�I �i Rha cc rr, . <br /> OWNER/OPERATOR <br /> Mike CHECK N BILLING ADDRESS <br /> FACRITY NAME <br /> Vanco Truck and Auto Plaza <br /> SITEADDRESS <br /> ;�-10'3✓ Stncl Number !) tion Charter Way SVeet Name Stockton cit '95Zip Code <br /> HOME or MAILING ADDRESS (ff Different from Site Address) <br /> Sheat Number SVeN Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION <br /> ( 209) 466-0833 <br /> PHONE92 En. BOS DISTRICT LOCATION CODE <br /> I ) i I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Terry Masters <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Elite IV Contractors 209 1 461-6337 <br /> HOME Or MAILING ADDRESS FAX p <br /> 2535 Wigwam Dr (209 ) 461-6342 <br /> CITY Stockton STATE CA LP 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 HEAL.TIA DEPARTMENThourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forn). <br /> 1 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: Ca44ZZ WWA4� DATE:� 4/19116 <br /> PROPCRTY/BUSINRSSOWNF.RO OPERATOR/MANAGER ❑ OT'HERAUTHORzEDAGENT'ICL Office Manager <br /> If.4PPuc.4A'T is Hot t/re R/U.IVG PARTY proof of auUurrizafion to sign is required Title <br /> AUTHORIZATION 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 CnITNTY ENVIRONMENTAL HFAL.TH DE.PARTMFNT 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: Replacment Of Smart Controller On Diesel Master <br /> COMMENTS: pAYMEN <br /> RECEIVED <br /> AM 2 0 2016 <br /> ENVOIRONMENTALTM <br /> ACCEPTED BY: / p EMPLOYEE#: E: Zp 1(g <br /> ASSIGNEDTO: L„fi� QjU - EMPLOYEE 9: DATE: /4 Z01V <br /> Date Service Completed (Italready completed): SERVICE CODE: y PIE: <br /> Fee Amount: �0,00 Amount Paid 3 LFj C, Payment Date <br /> Payment Type U� Invoice# Ghec S ) 1 Received By: A, <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />