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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID S SERVICE RE UEST# <br /> OWNER/OPERATOR <br /> STOCKTON UNIFIED SCHOOL DISTRICT CHECK if BILLING ADDRESS <br /> FACILITY NAME STOCKTON HIGH SCHOOL KITCHEN <br /> SITE ADDRESS 1621 BROOKSIDE RD. STOCKTON 95207 <br /> Street Number Dlrocdon Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1944 EL PINAL DRIVE <br /> Streat Numbor Street Namo <br /> CITY STOCKTON STATE CA ZIP 95205 <br /> PHONE 111 EXT. APN# LAND USE APPLICATION# <br /> (209)933-7045 2341 <br /> PHONE S2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REAQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ACME CONSTRUCTION COMPANY INC. PHONE it (209)-523-2674 Exr. i <br /> HOME or MAILING ADDRESS FAx# <br /> I' <br /> 1565 CUMMINS DRIVE ( ) <br /> Clry ZIP <br /> MODESTO STATE CA 95358 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> 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,ST Eand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT x❑ DIRECTOR, FACILITIES <br /> IfAPPLICANT is not the BILLING PARTY,pr of of authorization to sign Is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it is available and at the same time it i$•-frvvided to me or <br /> my representative. ���i 7Y! <br /> TYPE OF SERVICE REQUESTED: � ' <br /> COMMENTS: AIL 2w <br /> ' r)ll1-ad 14') 5-2D-603? SAN J0A <br /> ENVIIRQUt`V COUN <br /> �r�s� stuff�' <br /> NEA1-Ty p MEN�A11TTEN . <br /> ACCEPTED BY: / �.�� EMPLOYEE#: t DATE: (- r r- <br /> ASSIGNEDTO: EMPLOYEE#: f♦ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: %' PI : i <br /> Fee Amount; l� Amount Paid /�5Payment Date <br /> Paymont Type Invoice# Check# Received By: <br /> 1-30 K <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />