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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Community College jq m� <br /> OWNER/OPERATOR San Joaquin Delta Community College CHECK if BILLINGADDRES <br /> FACILITY NAME Delta College Manteca Farm <br /> SITE ADDRESS 5298 Brunswick Road Manteca <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) , Pacific Ave <br /> Street Number Street Name <br /> CITY STATE ZIP_ <br /> Stockton C <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 9.54-5741 N; ti p <br /> PHONE#2 ExT• BOS DISTRICT L <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR �C Q <br /> QAN�O <br /> Colin Culver CHECISjfEd61i <br /> BUSINESS NAME PHONE# lhYl SENT <br /> CNW Construction, Inc. 916 297-2446 <br /> HOME or MAILING ADDRESS FAX# <br /> 2520 Sierra Vista Road ( ) <br /> CITY Rescue STATE CA ZIP 95672 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: M �\ 'm Marina Nunez, KCEM DATE: 12/5/ 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT D Project Ma n a Lie i <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: New S e p t i C System <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Pa" z)K D(� Payment Date f 1 7� � <br /> Payment Type Invoice# q Check# Rece ved By: <br /> EHD 025 /�� SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 i `� <br />