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SAN JOAQUIP )UNTY ENVIRONMENTAL HEALTH 'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> School "7 S o o 4 9 -1 ct 2- <br /> OWNER/ <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Lodi Unified School District <br /> FACILITY NAME <br /> Woodbridge Elementar. School <br /> SITE ADDRESS 1290 Lilac Street Lodi 95242 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1305 East Vine Street <br /> Lodi Unified School District SlreetNumber Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209) 331-8052 C)i 5— 1-7 C —10 N/A <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) 331-7227 # 4 City <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � e` I / CHECK if BILLING ADDRESS�I <br /> BUSINESS NAME PHONE# EXT' <br /> 6 3 <br /> HOME or MAILING ADDRESS FAX# <br /> 0 5- <br /> CITY LOA I CA 95,aq0 <br /> STATE ZIP <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,S TE a d FEDERAL laws. , <br /> APPLICANT'S SIGNATURE: DATE: p� �O d -2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabkaand at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 10 O Uhl L C ! (—A-/V Gf-k L-C-e� �V <br /> COMMENTS: "SFV JOq 2 <br /> ' ?00? <br /> y �VViq�UiN co <br /> WTN p u, ry <br /> EM' <br /> ACCEPTED BY: D ( J Et�f� EMPLOYEE#: 3 Z' DATE: 2 ZZC� <br /> ASSIGNED TO: Fk-o f.(pZ,1flu EMPLOYEE#: '33� ( DATE: 124 Z 2{O <br /> Date Service Completed (if already completed): SERVICE CODE: s PIE: ( (o-C I <br /> Fee Amoun .-TT �S L� Amount Paid !' r Payment Date �a` v <br /> Payment Type Invoice# Check# � 3 vcJ P Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />