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� Y i <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 � <br /> OWNER/OPERATOR Frank Rubino Revocable Trust & CHECK If BILLING ADDRESS❑ <br /> Schmidt Family Revocable Trust <br /> FACILITY NAME <br /> SITE ADDREP74, 678, 681 W Grider Way Stockton 95210 <br /> P74 Street Number Oirecti tree ame � Co <br /> de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3(D 0$ W�D N s vm< C t✓De <br /> y <br /> CITY y.� Street Number trwt Name <br /> C I O 1 VY 1 STA4TE ZIP Cr ^ ^may <br /> PHONE#1 Ext. APN# LAND USEPPLIICCATION 8 <br /> (201) H-73 , 7 (o(o 070-140-28 FA - 0-7— <br /> PHONE#2 E0. BOS DISTRICT 2 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J i l"A F1V4itA S <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Eu. <br /> Associated Engineering, Inc 209 545-1143 <br /> HOME Or MAILING ADDRESS FAX# <br /> 4206 Technology Drive (209 ) 545-3875 <br /> CITY Modesto STATE CA ZIP 95356 <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 applicationa hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and CEDE laws. Dt <br /> APPLICANT'S SIGNATURE: „�• DATE: I / 1;k'10 S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT I9 P►vl rig raj <br /> ffAPPLICANT is not the BILLfVG PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator r the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or i nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avai ab a an at tt-ie]same, <br /> ame hme it is <br /> provided to me or my representative. JAP12 <br /> 8 2998 <br /> TYPE OF SERVICE REQUESTED: Surface Subsurface Contamination Report <br /> COMMENTS: /�6�h�-A,�-7Aa)1& 1 p � PERMIT/SERVICES <br /> A/ Ir 45�540071rc <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid ' 1 D a Payment Date (/;13 OF <br /> tuu <br /> Payment Type Invoice# Check# /12-1-0 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />