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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PUBLIC CHARTER SCHOOL I 7 <br /> OWNER/OPERATOR <br /> ASPIRE PUBLIC SCHOOLS CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> BENJAMIN HOLT COLLEGE PREPARATORY ACADEMY CAMPUS EXPANSION - INCREMENT 2 - TEMPORARY FOOD SERVICE <br /> SITE ADDRESS 3201 1 EAST MORADA LANE STOCKTON 95212 <br /> Street Number m Nafno City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT, APN# LAND USE APPLICATION# <br /> ( 209 ) 955-1477 N/A <br /> PHONE#2 ExT- BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CAROLYN CHOY - MANAGER, FINANCE 8 REAL ESTATE CHECK If BILLING ADDRESS El <br /> BUSINESS NAME ASPIRE PUBLIC SCHOOLS PHONE# Er <br /> 510 434-5507 <br /> HOME or MAILING ADDRESS FAX# <br /> 1001 22ND AVENUE ( 510 ) 434-5010 <br /> CITY OAKLAND STATE CA ZIP 94606 <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,,titandc{rds,STATE-an ,EDERAL laws. // <br /> APPLICANT'S SIGNATURE: I V <br /> DATE: �A <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/iV NAG�R ❑ OTHER AUTHORIZED AGENT I myt' LC g. <br /> !f APPLICANT Is not the BILLING PARTY proof Of authorization t0 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 environmentaUsite 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: QIC(,►') �/� <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: I P i E: I ` <br /> Fee Amount: p.(�p Amount Pai yD Payment Date a� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />