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2016-11-10 14:37 Visplia Sales 15597320817 >- 2094683433 P 1/2
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<br />—NOU Q 2016 SERVICE REQUEST
<br />Type of Business or Property
<br />ENVIRONMENTAL HEALTH
<br />Valley Pacific petroleum
<br />%v,�Ty NAVE Fresno Ave Cardlock
<br />SITE ADDRESS
<br />HOME or MAILING ADDRESS (11 Diflotent front Site At;ldr"-s)
<br />CITY
<br />Stockton
<br />PHwiiirl
<br />;209) 993-8793
<br />Nout,42
<br />1209) 948-9412
<br />F APN $I
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<br />FACILITY 10
<br />SERVICE REgUEii':_'
<br />CHL -CIS it 166LINc.
<br />S;i�, 4a 15-Z06>
<br />152 Frank West Circle
<br />",troott Numher
<br />ST A I t:
<br />zip
<br />CA 95206
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<br />I _ios -DISTRICT LOCATION CO -11-
<br />322
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUeSTOR Mike Eliason
<br />BUSINESS NAME
<br />vallex Pacific Petroleum
<br />HOME OF MAILING ADDRcss
<br />152 Prank West Circle
<br />CIT- Stockton
<br />CHECX it BILLING ADDREI.S0
<br />PHO14F A
<br />(209) 993-8793
<br />FAX 0
<br />559 1 732-0817
<br />STATE CA Y zip 95206
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<br />.ki'l HokIZATIONTO RF.1,FASF, INFORNIA11ON- 1klicn applit;able. 1. flit: imrivr lit operator
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<br />ACCEPIEr, BY;
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<br />AsSIGNCD TO'.
<br />LOYLE A7
<br />DATr
<br />Date Service Completed (if already completed): C00t
<br />Fee Arnount! Amount Paid Payment Date
<br />Payment Type Invoice 0 I Cheek # Recoived By:
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