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SAN JOAQU. COUNTY ENVIRONMENTAL HEALTk _,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMERCIAL <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />DAVE GUARDINO CHECK if BILLING ADDRESS <br />FACILITY NAME GUARDINO AND CRAWFORD CONSTRUCTION <br />SITE ADDRESS 517 <br />Street Number <br />WEST <br />Direction <br />FREMONT STREET <br />Street Name <br />STOCKTON <br />City <br />95203 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />City STATE ZIP <br />PHONE #1 EXT. <br />( 209 ) 467-1006 <br />APN # <br />137-214-10 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ERIN ROTTACKER CHECK if BILLING ADDRESS X <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. <br />PHONE # <br />( 209 ) 467-1006 <br />Exr. <br />HOME or MAILING ADDRESS <br />837 SHAW ROAD <br />FAX # <br />( ) <br />Ci-rv 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, STATE and FEDERAL laws. <br />AA,., ________ Dm.: 12 FEBRUARY 2018 <br />PROPERTY / BUSINESS OWNER': OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT II STAFF 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: <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 />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003