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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> St. Mary's High School CD4qGIC)Z <br /> OWNER/OPERATOR // <br /> CHECK If BILLING ADDRES <br /> St. Mary's High School S <br /> FACILITY NAME <br /> St. Mary's High School <br /> SITE ADDRESS <br /> 5648 Street Number I Direction N. EI Dorado S;treat Name Stockton c. 95 coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 7247 Street Number I Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95267-0247 <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> (209 )957-3340 249 `O2 DA0O 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 ) 565-7992 0 U 2— <br /> CONTRACTOR <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST / <br /> L.) Ir � co , CHECKifBILLINGADDRESS- <br /> BUSINESS NPHONE# EXT. <br /> r4� ICIlr a�, `s -33'16 Z a <br /> HOME or MAILING ADDRESS FAx# <br /> LI. k S ( ) <br /> CITY Q C- - � _\ STATE C In ZIP .i\ <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: � T-f'(e � DATE: QT 1 b� 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER p OTHER AUTHORIZED AGENT❑ <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 t0 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 /> PAYMENT <br /> COMMENTS: RECEIVED <br /> Q116 10 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: - b�/J.n,\ ==EMPLOYEE#: DATE: <br /> ASSIGNED TO: Cit rym e5 C-D EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �(P ` PIE: LP('Z <br /> Fee Amount: Ac5r2 ,OD Amount Paid `152 , 00 Payment Date g` tb l g <br /> Payment-Type Invoice# Check# �'t�OZ Received By: 1500) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />