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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Retail Gt 00 C:) <br /> OWNER / OPERATOR <br /> Mike Popari CHECKIfBILLING ADDRE5SE] <br /> FACILITY NAME VANCO Truck & Auto Service <br /> SITE ADDRESS 1033 W Charter Way Stockton , CA 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 466-0833 <br /> PHONE #2 ExT. BOS DISTRICTco LOCATIOUDODE <br /> ( ) w <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 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 /> I 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 /> rAPPLICANT' S SIGNATURE • ' DATE ; 09/ 14/2021 <br /> PROPERTY / BUSINESS OWNER 13 OPERATOR / A4 NAGER 13OTHER AUTHORIZED AGENT El Administrative Assistant <br /> NEENEW <br /> IfAPPLICAN7' 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 <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 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: (� f -ifPit <br /> COMMENTS : <br /> S4 SEP 5 20? <br /> FN o'4 QUI <br /> yEq � lH o pq�N p CNT y <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ( Gt /, / r D EMPLOYEE M DATE : 1/� <br /> Date Service Completed (If already completed ) : SERVICECODE: �ZLI� PI E: .��jCj <br /> Fee Amount: Amount Pai , � Payment Date 1 <br /> Payment Type �/y Invoice # Check # I 2ff / � 7 is Re'ceiv d By: ZeH <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />