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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JUL 11 2016 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVIC T)F <br /> i <br /> Truck Stop t�3 cSr/�C C ]< <br /> 21 <br /> OWNER/OPERATOR <br /> Mike CHECK If BILLING ADDRESS <br /> I <br /> FACILITY NAME I <br /> Vanco Truck and Auto Plaza <br /> SITE ADDRESS W Charter Way Stockton 95205 <br /> 1033 Street Number Direc ion t et Name City zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stmet Number Street Name <br /> CITY STATE ZIP ' <br /> PHONE#t Ear• APN# LAND USE APPLICATION# <br /> (209 ) 466-0833 1 1Q �LI <br /> PHONIER En. BOS DISTRICT LOCATION CODE <br /> ( 916) 396-1665 Cj O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Terry Masters CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# Ex. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( 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 /> 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.s,n <br /> APPLICANT'S SIGNATURE: ( NZ� DATE: 7/11/16 <br /> PROPERTY/BUsuirssOwNERO OPERATOR/MANAGER O OTHER AUTHORIZED AGENT Office Manager <br /> If APPLICANT is not the PILLING 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: (5) Fill buckets to be replaced PAYMENT <br /> COMMENTS: Cx RECEIVED <br /> p�d l><ed <br /> JUL 12 2016 <br /> SAN JOAQUIN COU <br /> ENVIROMENTAL <br /> HEALTIJ IDEPARTMEM <br /> ACCEPTED BY: Q e EMPLOYEE#: DATE: <br /> + �u - /a 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE; -7 <br /> Date Service Completed (If already completed): SERVICE CODE: C) PIE:P1E: 3 <br /> Fee Amount: , Amount Paid Jr$S ob Payment Date -7 12 1({ <br /> Payment Type VtSp Involve# Cheek# VISA. 6lt ty.L( Received By: -7DjDI <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />