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SAN JOAQUIN ,OUNTY ENVIRONMENTAL HEALTH ,_,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Warehouse Storage Facility <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />HECK Charles & Donna Skobrak Trust BILLING ADDRESS <br />FACILITY NAME <br />Larry's Auto <br />SITE ADDRESS <br />308 Street Number Direction <br />North Grant <br />Street Name <br />Stockton <br />City <br />95215 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />9947 Street Number <br />East Hwy 26 <br />Street Name <br />CITY STATE ZIP Stockton CA 95215 <br />PHONE #1 EXT. <br />(209 ) 465-2667 <br />APN # I LAND USE APPLICATION # <br />139-320-13 NA <br />PHONE #2 Ext. HOS DISTRICT <br />( 1 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Daniel Villanueva -Advanced GeoEnvironmental, Inc. CHECK if BILLING ADDRESS II <br />BUSINESS NAME <br />Advanced GeoEnvironmental, Inc. <br />PHONE # <br />( 209) 467-1006 <br />Err. <br />HOME or MAILING ADDRESS <br />837 North Shaw Road <br />Fax # <br />( 209 ) 467-1118 <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 />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 Ordinance Codes, Standards, STA nd FEDERAL laws. <br />A PPT,TCA N1-'15 UGNATTJPEe'-' DATE: / 2- <br />PROPERTY/ BUSINESS OWNERD OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El Project Geologist <br /> <br />lpIPPLIcANT 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: Grout Inspection - Boring Abandonment <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: <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