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I also certify that I have prepared this applic <br />COUNTY Ordinance Codes, Standards, S <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER!: 0 ERATOR / MANAGER 0 <br />o be performed will be done in accordance with all SAN JOAQUIN <br />DATE: <br />OTHER AUTHORIZED AGENT Ri STAFF GEOLOGIST <br />e wor <br />laws. <br />d th <br />SAN JoAQuillipUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMERCIAL <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />CHECK if JH Simpson Company, Inc. BILLING ADDRESS <br />FACILITY NAME JH Simpson Company, Inc. <br />SITE ADDRESS 4025 <br />Street Number Direction <br />Coronado Avenue <br />Street Name <br />Stockton <br />City <br />95204 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209) 467 -1006 <br />APN # <br />115-300-25 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Rene Toth CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC <br />PHONE # EXT. <br />( )209-467-1006 <br />HOME Or MAILING ADDRESS <br />837 SHAW ROAD <br />FAX # <br />( ) <br />crry STOCKTON STATE CA zip 95215 <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 />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 OF SERVICE REQUESTED: RECEIVED <br />COMMENTS: FEB 11 8 2W: <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERV!CFS <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/ E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003