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X aVREG} Revised 5/13/93 <br /> SERVICE REQUEST 3` <br /> BILLING PARTY 3L/Y �»- <br /> RECORD iI) # <br /> fACILITY ]D # <br /> Municipal Utility Facility <br /> FACILITY NAME. �a <br /> 4 <br /> SITE ADDRESS 2500 Nav ' Drive <br /> CITY <br /> Stockton CA ZIP <br /> BILLING PARTY r / N <br /> OWNER/OPERATOR Cit of Stockton <br /> PHONE #1 <br /> DBA <br /> 425 N. Fl Dorado Street PHONE #2 ( �— <br /> ADDRESS 95202 <br /> CITY Stockton <br /> STATE CA ZIP <br /> SOS <br /> city Code= <br /> Location Code <br /> City Code --'--- <br /> APN # <br /> CONTRACTOR and/or EEE= <br /> SERVICE REQUESTOR Ellvl-ronTllental Constructl(]n <br /> PHONE #1 ( �� <br /> DSA <br /> MAILING ADDRESS BOX <br /> 233134 FAX # <br /> CITY SacrA <br /> STATE CA ZIP 95823-3134 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> LING PARTY on <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BIL <br /> Page 1 of 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 <br /> JOAQUIN COUNTY ordinance Codes and St dards, State a eral laws. <br /> APPLICANT'S SIGNATURE .Y <br /> Manager Date: <br /> title: Owner/ -� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided <br /> /t�o me or my representative. <br /> Service Code <br /> Nature of Service Request: �-3 <br /> Assigned to /L l. / is ( eYT Employee # V Date <br /> Further Action Required: Y / N PROGRAM ELEMENT <br /> Date Service Completed <br /> Fee Amount Amount Paid Dake of Payment Payment Type Receipt # Check # Recvd By <br /> RENS / / SUPV i/ / ACCT / UNIT CLK _/ / <br />