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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Stockton TerminalI� <br /> 'S�oo <br /> OWNER/OPERATOR <br /> Stockton Terminal Eastern Railroad Co. CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Stockton Terminal-Stokes Avenue <br /> SITE ADDRESS North Stokes Avenue Stockton 95215 <br /> 1177 <br /> Street Number I Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION At <br /> ( 510 ) 835-7251 143-280-01 <br /> PHONE#2 EXT. BOS DISTRICT--7LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR x <br /> Rosa Chen /Vitaliy Kostromitin CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> TrainSystems 510 835-9899 <br /> HOME or MAILING ADDRESS FAX# <br /> 2000 Center Street,Suite 303 ( ) <br /> CITY Berkeley STATE CA ZIP 94704 <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 /> Digitally signed by Rosa Chen 6/18/19 <br /> APPLICANT'S SIGNATURE: C Date:2019.06.1909:22:41-07'00' DATE <br /> PROPERTY/BUSINESS OWN ER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project 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 <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 01 TED: <br /> COMMEiML- <br /> JUN 2 5 2019 <br /> SAN JO p IN COUNTY <br /> ENV ONMFNTAL <br /> HDEBAR MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pal �03`vv Payment Date <br /> Payment Type Invoice# Check# 26DOD Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />