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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Private property - Commerical S 1� Db - D S <br /> OWNER / OPERATOR Spaulding Trust Property C/O Will Namnath <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Spaulding Trust Property <br /> SITE ADDRESS 540 North EI Dorado Street Stockton 95203 <br /> Street Number Direction I Street Name city Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) 1434 Third Street , Suite D <br /> Street Number Street Name <br /> CITY Napa STATE CA ZIP 94581 <br /> PHONE #1 EXT. APN # 139-060-39 LAND USE APPLICATION # <br /> ( 707 ) 812-1426 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR William Little 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 /> ( ) <br /> CITY 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 /> 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 Or �aMe Codes, Standards, STATE and FEDERAL laws . <br /> s . <br /> APPLICANT' S SIGNATURE t � T- • DATE : <br /> ry � � � I� <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ W WID AGENT IN Agent <br /> IfAPPLICAATis not the BILLINGRAIRTY, proof of authorization to sigh is regrrired 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 : S <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> SEP18 2016 <br /> SAF! JOACIUIN COUNTY <br /> ENVIROMEN'TAL <br /> ACCEPTED BY : <�- (l� EMPLOYEE #: DATE: •a J� <br /> ASSIGNED TO : � , EMPLOYEE #: DATE: <br /> Date Service Completed (if already Completed ) : SERVICE CODE : o - j P 1 E : cap <br /> Fee Amount: I � -'� ��� Amount Paid �kl `1 od Payment Date q 2S llp <br />�I <br /> Payment Type � tL Invoice # Check # a ���$ Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />