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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Former UST location <br />FACILITY ID # <br />-.---- <br />p c L.. c_ :) / <br />SERVICE REQUEST # <br />ii, CL' - 0 07-6 (:./ '7 S <br />OWNER! OPERATOR <br />CHECK if Ray Farmer Enterprises Inc. BILLING ADDRESS <br />FACILITY NAME <br />Former Toyota Town <br />SITE ADDRESS <br />610 Street Number Directio n <br />Hunter Street <br />Street Name Stockton City <br />95202 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 2606 <br />Street Number <br />Sheridan Way <br />Street Name <br />CITY STATE ZIP <br />Stockton CA 95207 <br />PHONE #1 EXT. <br />( ) <br />APN # <br />139-060-33 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Jeanne Homsey CHECK if BILLING ADDRESS X <br />BUSINESS NAME PHONE # EXT. <br />ATC Group Services LLC ( 209 ) 579-2221 <br />HOME or MAILING ADDRESS FAx # <br />1117 Lone Palm Avenue, Suite 201B ( 209 )579-2225 <br />CITY Modesto STATE CA ZIP 95351 <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 />DATE: <br />PROPERTY / BUSINESS OWNER 0 0 RATOR / MANAGER 0 OTHER AM HORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: 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, 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: /4- <br />COMMENTS: <br />ACCEPTED BY: fl F4Le4 1,i-,i-t--- EMPLOYEE #: (') /7 c di DATE: 3/ /I 471 7 <br />ASSIGNED TO: ag-,,..f A4-t EMPLOYEE #: <br />P:1( <br />DATE: i , // 7 <br />Date Service Completed (if already completed): SERVICE CODE: e..- ..s P1 E: zg 0:37 <br />Fee Amount: - / '7 Amount Paid ir / 7 Payment Date 3/ V/ .7 <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003