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SERVICE REQUEST EH0061SR revised 07/10/98 Type of Business or Property FACILITY ID# SERVICE REQUEST# 0/ Sa OWNER/OPERATOR Norma Norton BILLING PARTY® FACILITY NAME SITE ADDRESS 30327 East Highway 120 Street Number Direction Street Name Type Suite k Mailing Address (If Different from Site Address) CITY STATE ZIP PHONE#'I EXT. APN# 229-170-83 LANDUSEAPPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR f SERVICE REQUESTOR REQUESTOR NOA Environmental BILLING PARTY El BUSINESS NAME PHONE# EXT. 20 367-3701 MAILING ADDRESS FAX# 22 N. Houston Lane 20 369-4228 CITY LOCH STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity will be billed t0 me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards,STATE and FEDEPkL laws._ %r APPLICANT SIGNATURE: DATE:, PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLINGPARR proof of authorization to sign Is required Title AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ l'Fsc ,r-. MAR e 5 1999 SAN JOAQUIN CUUNT 0141 LIC HEALTH AL HFAt Tpl DiVISIOr" INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE:-7 _Z1 1- > APPROVED BY: EMPLOYEE#: DATE: �G ASSIGNED TO: EMPLOYEE#: (J DATE: Date Service Completed (if already completed): SERVICE CODE: ZZ Fee Amount: ( Amount Paid Payment Date s Payment Type Invoice# Check# &q 7,V Received By.