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F 0 <br /> SANJOAQlrnv COUVTV ENVIRONMENTAL REALT111DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATW Charles Skobrak CHECK if BILLING ADDRESS® <br /> PAUCITY NAME. <br /> SIrEADDRESS 9947 E Hwy 26 Stockton 95.205 <br /> S at Number Diroetian . Caft <br /> HoMEorMALWADDREss (If Different from Site Addto") <br /> Numtift <br /> CITY Stockton 'SrATZ CA :ZIP 95205 <br /> PHONE41 APNii - LAND USE:AAK&ATim# PIf-�-/�.� <br /> (209)603-6329 089-100-09 Minor Subdivision J <br /> PHONE>I2 ...EIS/. "$OS t)15TRICT LGGATibN CODE :'`: <br /> ) <br /> CONTRAGPDR f SERVICE REQUESTOR <br /> REQUESTOk <br /> Ally L.Colavita W(ECK'd$I11- wc,400REss❑ <br /> Buslk"sNAME Advanced Geo Environmental,Inc. �PHWE1r (209)467-1006 <br /> HOMEorMA LING ADbREss 837 Shaw Road F1?r (209)467-1118 <br /> CITY Stockton :STATE CA Zip 95215 <br /> BILLINCr AQQj9WL&3jgjWW ,, 1, the-undmigned property or business 4wrtcr; operator or u'utporioed:agcnt or,siuie; <br /> ucknov4 wige dim all:alto,iitW.0r pmtopt spati$c EW-MONMENTAL HEA:m DtmAacTstENa'hourly oh rgas asstieirttal.wiffi ihix 11ro opt <br /> or activity W10*1[silleidtumearmylusifte4:ati'l patiflodonthisfurrriL <br /> i aUocc fify Utat I llsvC prcPared thisappliontitm and'thatthc work"1u:tic perftxtrted wYlt.lietkmc in accordance N!ittriell tshNJ9AQ1M <br /> WNTY C#Auranre-C,�ts,StUndnrda,�/ST�- �,htt FT9EIUL iawy. <br /> APMCANTIS SI04ATLTRE �, > ' & - <br /> PRomiymu no yr Owmk ca 0P$R0.(Mf IMANACEA.E3 .OTABa AxalfbRtz*6 AtvxT E3 6&0r� <br /> If ARPUIC,fNr&Wotthe BILLING P.4 propf of aul*ori;;don Yo sign iv required Title <br /> A l-TH( AIZATION TO`RELR,ASE,iNFCyYtMA1 i(3jQ:Whm applicable,1,the owner or operator of thcproperty located at the <br /> above site address, hereby authorize the ralcatie:.of any and.all retiults, gcotec:hnical dataandtor-cmriromnentalfsitn ussossmient. <br /> nfonnation to the::SAN-JOAquw Ca NTY ENvtitoNMENTAL HHALTH IEYARTMEN-Pas soon:as it is available and at-the"satfle;4imc it is <br /> -provided tone or my repmsentative: <br /> TW96F.SERWCE-REQUE57ED: („ C-I <br /> Comm- PAYMENT <br /> RECEIVED <br /> Soil Suit/ability Study <br /> �6&-TR�' ��r00 JUN 2 5 2008 <br /> M' c- C SAN JOAQUIN COUNTY <br /> (Orr �'yyy �/ ��y(��]� ENVIRONMENTAL <br /> APPRowo eY: � EMPLOYEE#: 5! "' <br /> ASSIGNED TO �i^ - EMPLOYEE#:. � DATE. <br /> Date Service Completed (if already completed): BER. '-F CODE: S v�� P lE: <br /> Fee Amount: ae Amount Paid ti Payment Date '� (, `' <br /> __._. __ _ _ <br /> Pa ment Type Invoice# Check# —~ ` , v <br /> __. <br /> Y YP v � _ RecervedBy: <br /> EM,48-01.026- SERVICE REQUEST FORM <br /> REWEDS`r5-02: <br />