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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALT0EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lawnmower Repair Yard <br /> OWNER I OPERATOR <br /> HECK BILLING ADDRES <br /> Jianping Wang S <br /> FACILITY NAME Fernando's Place <br /> SITE ADDRESS Sout Center St Stockton 95206 <br /> 1201 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Ralph Avenue <br /> 1903 Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> (209 ) 390-7218 147-160-03 NA <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Brian Millman-Advanced GeoEnvironmental, Inc. <br /> BUSINESS NAME PHONE# ExT. <br /> Advanced GeoEnvironmental, Inc. 1 209 ) 467-1006 <br /> HOME Or MAILING ADDRESS FAX# <br /> 837 North Shaw Road ( 209) 467-1118 <br /> CITY Stockton STATE GA ZIP 95215 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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, STATE and FEDERAL laws. <br /> k.l?]zL CA1iT` a rI?7:T1J1ZE: &U ,'�I'V J1_- (Brian Millman) DATE: 7/21/17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® Project Geologist <br /> If APPLICANT 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 - Soil Boring Permit <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M 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 /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />