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SAN JOAQUIN AJNTY ENVIRONMENTAL HEALTH 1OARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Auto Repair Shop <br />FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR <br />HECK <br />Roberto Merlos <br />BILLING ADDRESS <br />FACILITY NAME <br />Dominic's Auto Tech <br />SITE ADDRESS <br />435 Street Number Direction <br />North Harrison Street <br />Street Name <br />Stockton <br />City <br />95203 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />same as site address Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />(209 ) 762-2753 <br />APN # <br />137-250-060 <br />LAND USE APPLICATION # <br />NA <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Daniel Villanueva - Advanced GeoEnvironmental, Inc. CHECK if BILLING ADDRESS EJ <br />BUSINESS NAME <br />Advanced GeoEnvironmental, Inc. <br />PHONE # <br />( 209 ) 467-1006 <br />EXT. <br />HOME or MAILING ADDRESS <br />837 North Shaw Road <br />FAX # <br />( 209) 467-1118 <br />Orr 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 E and FEDERAL laws. <br />A. FUCA I\IT'E 21-G-NATIJFE: <br />PROPERTY! BUSINESS OWNER': OPERATOR / MANAGER 0 <br /> DATE: 3.A8 -18 <br />OTHER AUTHORIZED AGENT 121 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Project Geologist <br />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 <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003