Laserfiche WebLink
2014-03-07 13:07 VPPS STOCKTON 12099480755 » 2094683433 P 1/1 <br />SAN JOAQ,,,N COUNTY ENVIRONMENTAL HEALTH LEPARTMENT <br />SERVICE REMPST <br />I,VIN I KAC'1VR / SERVICE REQUESTOR <br />REQUESTOR <br />Mike Eliason CHCCK It BILLIN<;DDRE a <br />BUSINESS NAME Valley Pacific Petroleum Services, Inc. PHONE# EXT. <br />209 948-9412 <br />HOME or MAILING 152 Frank West Circle, Suite 100 FAX il <br />1 209 1 948-0755 <br />CITY Stockton STATE CA ZIP 95206 <br />RILLIN.(:_ACKNOWI.FOCEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project SpCCific ENVIRONMENTAI, HEALTH 01,11ARTMENT 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 1 have prepared this application and chat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards-, STATE and FEDL'RAI, laws, <br />APPLICANT'S SIGNATURE: �'r Dn317 <br />'rr;: <br />PROPFIOV / BUSINESS OWNER❑ OPERATOR t MANAGE14 Q 0-ri1FR AUTnORI'/,ED Ac. ENT ❑ <br />ifAPPLICAA'T is not lite 13111.1,vr, P;fRTY, proof of aatilOrilation to sign is required Tlrrc <br />A1JT110RIZAT10N TO RELFASIE INEQRMATION: 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, 9cotechnical data and/or environmental/site assessment <br />information to the SAN JQACUIN COUN'T'Y 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 $ERVICE REQUESTED: Annual Monitor Certification <br />COMMENTS: <br />Requesting for Friday, March 14,2014 at 8:30 am, <br />07 / ! 14 <br />4"NVIRONME NT <br />AL <br />DATE: <br />ACCEPTCO BY: EMPLOYEE #: °.14T <br />ASSIGNED TO: EmpLOYEE #: <br />DATE: <br />Dato Sorvico Completed (If alroady complotod ): $t2RVICE CODE: P I E: <br />Foo Amount. Amount Paid Paymont Dato <br />Payment Typo Invoico # Chock * Roceivod 8y: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Goldon Rod) <br />