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Ramcon will pay all fee's necessary to obtain the initial permit. <br /> An)v other fee's will be the reslity of the Stockton Devel ntal Center. <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID f! 1 � .— INVOtil*�# i(;��p -�d]A� <br /> FACILITY NAME Stockton Developmental Center BILLY® rj RIOM4 <br /> SITE ADDRESS 510 East Magnolia Street <br /> CITY Stockton CA ZIP 95202 <br /> OWNER/OPERATOR Stockton Developmental Center BILLING PARTY / N <br /> DBA Same (Boiler Plant) PHONE #1 ( 209 948-7411 <br /> ADDRESS 510 East Magnolia Street PHONE #2 ( 209 948-7328 <br /> CITY Stockton STATE CA ZIP 95202 <br /> APN # Land Use Apptica[ion # <br /> FBOS Dist Location Code <br /> CONTRACTOR and/or —•— <br /> SERVICE REQUESTOR Ramcon Eng. & Environmental Contracting, Inc. BILLING PARTY / N <br /> DBA Same PHONE #1 ( 916 ) 372 - 7535 <br /> MAILING ADDRESS 3751 Commerce Drive FAX # ( 916 1 372-4209 <br /> CITY West Sacramento STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 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 Standards, State and Federal laws. icf MENT <br /> APPLICANT'S SIGNATURE ��� M1Chae1 S. Ramos n,E 2 a 1996 <br /> Title: Contractor/Owners - Agent Date: 6-28-96 <br /> IN COUNTY <br /> PUBLIC HEALTH SER�yI� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owriph;�pperatp�l�-J�t �'�''N dl Oof <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data a 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 to me or my representative. <br /> Nature of Service Request: �� ServSce Code <br /> l yt (.l 1 <br /> Assigned to Employee # coo Date 7" <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �L3 <br /> REHS /_ SUPV / /_ ACCT I / / UNIT CLK / /_ <br />