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r <br /> SAN JOAQUIN COUNTY ENIvIRONMENTAL.HEALTH DEP.ARTMEI\r <br /> SERVICE REQUEST <br /> Type ofBusiness orProperty" - - FACILITY ID# SERVICEREQUEST# <br /> OWNo6 <br /> ERJOPERA;OR ChaziesSkobiak CHECK if81WNG E <br /> FAOLITY NAME. <br /> SREAWREsS 9947 E Hwy 26 Stockton 95205 <br /> %ep NurM¢r Dim NameCRY <br /> HOMEor MlALNG ADDRESS (If Different from Site-Address) <br /> Senses NunDer <br /> crr9 Stockton -STATE CA zap 95205 <br /> PANENt Exp, APN# LAND USE APPLICATION <br /> (209)603-6329 089-100-09 Minor Subdivision <br /> NONE#2 E'. BOSDISTRICT LOCATIONCODE <br /> ! i <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REOUESTOR <br /> Ally L.Colavita GNECK fi BNSING AooREss❑ <br /> BUNNESS NAME Advanced Geo Environmental,Inc. PH°NE# (209)467-1006 En" <br /> HOME orMmuNoADDRESS 837Shaw Road F"0 <br /> (209)467-1118 <br /> CITY Stockton STATE CA zIP 95215 <br /> BILLING ACKNOWLEDGEMENT: 1, tM undersigned property or business owner, operator or autberized.agent of sante, <br /> uckoowledge that all site and/or project specific ENVI oNMENTAL 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 prep red this application and that the work to be perfo rmed will be dome i'n acccodaocc with-all SAN JnAQT1W <br /> COUNTY Order- nre-Coder;Standardg,STATE and FEDERAL laws. n <br /> APPLICANT'S SIGNATURE:. . . -I-(- • DATE:. 6- aS Or <br /> PROPERTY.)SUIUNESS OWNER® OPERATOR/MAN.AGER.L] OMER AUMORTZED.AGENrO <br /> ffAppr ICAN, T is not the Buss's Pnx['i'.Pmofof aurhoriadon to sign is reg Mired Tate <br /> AIT RORIZATION TO RELEASE]INFORMATION:Whcn applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby m6wrin the release:of any and all results, geotechnical data and/or crivironmcnta/site assessment: <br /> information to the:SAN JDAtlt rN COUNTY ENVIRONMENTAL HEALTH:DEPARTMENTmssoon as it:is available:and at the same time it is <br /> provided to me or my.representative. <br /> Type OF SERvicE REQOF87ED: ENT <br /> commas: <br /> Surf c and Subsurface Contamination Report RECEI <br /> �t1� ��° r � 7'17810 JUN 2 5 ZOOS <br /> 0 F �cAr7c 3 <br /> ,2 > SAN JOAO iMENT L <br /> _--- - - -- <br /> VIRONMENTAL <br /> APPROVED BY' <br /> EMPLOYEE#: DATE}{ T <br /> ASSIGNED TO — K/1/T{i(� — EMPLOYEE#: DATE: <br /> Date Service Completed (iflalmaddy completed): SERYCE.COOE: "r P(E; <br /> Fes Amount: N Amount Paid . ,��,y t F i� - <br /> Payment Date <br /> Payment Type L,'--' Invoice Chek . t—;; �- --� --- <br /> Received By: <br /> EEVISED•026 SERVICE REQUEST FORM <br /> REVISED6-5-02 <br />