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UAN JOAQUIN (_ oIJmAy E' NVIRONMERI'IA . I'l- FAIAT: -4-A ) ARTMENT <br /> C <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel <br /> OWNER / OPERATOR <br /> Mike Popari CHECK ifBILLING ADDRESS ® <br /> FACILITY NAME Vanco Truck Plaza <br /> SITE ADDRESS 1033 W. Charter Way Stockton 95206 <br /> Street Number Directlon Street Name Cit ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SAME <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 466- 0833 site <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( 916 ) 396- 1665 7711 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209y461 "6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 2o9 ) 461 -6342 <br /> CIN 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : C?45zoot � NWA12-- DATE : 10/23/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ef Office Manager <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It is provid<Spkfie Or <br /> my representative . I� <br /> , YT <br /> TYPE OF SERVICE REQUESTED : V, 76 <br /> COMMENTS : V O <br /> 'sAN ,, 6 423 <br /> TH�cNMSN( UNTy <br /> EPgRT FNT <br /> ACCEPTED BY: J EMPLOYEE M DATE: J(� <br /> ASSIGNED TO : i p , �I EMPLOYEE M DATE: <br /> Date Service Completed (if already comple ed) : L ( ' — SERVICE CODE : r ei 49;29?4p PI E: 2,30 F <br /> Fee Amount: �/ (�; ° Amount Paid [�g6 cc) Payment Date <br /> Payment Type V l xInvoice # Check # �$ L} 3 386 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />