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SAN JOAQUPWUNTY ENVIRONMENTAL HEALTY - EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Commerical C)-J' 144 <br /> OWNER/OPERATOR <br /> City of Stockton CHECK If BILLING ADDRESSE] <br /> FACILITY NAME City of Stockton - 800 East Main <br /> SITE ADDRESS 800 E Main Street Stockton 95202 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 22 East Weber Avenue, Room 301 <br /> Street Number Street Name <br /> CITY Stockton STATECA ZI995202 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 937-8374 NA <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Robert Marty CHECK If BILLING ADDRESS <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. PHONE# EXT. <br /> 209 467-1006 <br /> HOME or MAILING ADDRESS 837 Shaw Road FAx# <br /> ( 209 ) 467 -1118 <br /> CITY Stockton STATE CA ZIP 95215 <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STA ya d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER® ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT 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. ,n f� �� f <br /> TYPE OF SERVICE REQUESTED: u TVA / 'Dwl/1H I RV D <br /> COMMENTS: <br /> SEP 15 2015 <br /> ENVIRONMENTAL <br /> UFAITN n9:P.4RTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: -7/15/1 <br /> ASSIGNED TO: VO EMPLOYEE#: DATE: dI /S. 11�; <br /> Date Service Completed (if already completed): SERVICE CODE: �v(� PIE: 22U <br /> Fee Amount: Amount PaicF73�b.�� Payment Date /r S <br /> Payment Type Invoice# Check# 2-Z31 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />