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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> High School Farm <br /> OWNER/OPERATOR <br /> Escalon Unified School District CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Escalon High School Ag Farm Complex <br /> SITE ADDRESS <br /> 17970 South Van Allen Road Escalon 95320 <br /> Street Number Direction Street Name city ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1520 Yosemite Ave. <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> Escalon CA 95320 <br /> PHONE#'I EXT• APN# ! �C i �a- I LAND USE APPLICATION# <br /> Zc _ — <br /> ( 209 )838-3591 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Clark CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> TPH Architects 2 571-2232 <br /> HOME Or MAILING ADDRESS FAX# <br /> 519 McHenry Ave. ( 209 )571-1936 <br /> CITY Modesto STATE CA zip 95352 <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 /> APPLICANT'S SIGNATURE: �C � DATE: l� r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: i-e 0 RECEIVED <br /> COMMENTS: , a_, ` ��VMAY <br /> 15 <br /> 2019 <br /> � � Mtar� SAN JOAQUIN COUNTY <br /> I r Nv ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ZZ EMPLOYEE M DATE:.5-11 �5G�U <br /> / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 P/E: 6 p <br /> Fee Amount: G7 Amount Paid v _ Payment Date `J <br /> Payment Type Invoice# Check# d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />