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SAN JOAQUIN JUNTY ENVIRONMENTAL HEALTH ?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR NANCY SANGUINETTI CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME SANGUINETTI TRUST PROPERTY <br /> SITE ADDRESS 2085 E MARIPOSA ROAD STOCKTON 95205 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2928 DWIGHT WAY <br /> Street Number Street Name <br /> CITY STOCKTON STATE CA ZIP 95204 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 559 ) 709-0942 171-290-040 <br /> PHONE#2 ExT. BOS DISTRICT--7LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TIMOTHY J. CUELLAR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. P"�pg yr# ExT. <br /> 323-6515 <br /> HOME or MAILING ADDRESS 837 SHAW ROAD FAx# <br /> ( 209) 467-1118 <br /> CITY 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. 'p <br /> APPLICANT'S SIGNATURE: 1 DATE: p3 20\6 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT ANAGER ❑ OTHER AUTHORIZED AGENT IR LAO,Pc,T MANA"-'— <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 /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />