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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Elementary School <br />CK 1(BILLING ADDRESS <br /></C�� — fi�ilf: -' - ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNERIOPERATOR Lodi Unified School District <br />CHECK It SILUNG ADDRESS® <br />FACILITY NAME Houston School <br />'`161 921-2212 <br />SITE ADDRESS 4600 <br />Street Number <br />I DI.O.. <br />Acampo Road <br />StM,J Nemo <br />HEALTH ENTAL <br />Acampo <br />chy <br />95220 <br />Zip Code <br />HOME or MAILING ADDRESS (It Different from Site Address) 1305 <br />S"et Number <br />E. Vine Street <br />net Name <br />CITY Lodi <br />STATE CA ZIP 95240 <br />PHONE #1 <br />(209) 331-7225 <br />API # <br />01731001 <br />r <br />I <br />LAND USE APPLICATION It <br />PHONE #2 <br />SERVICE CODE: t" <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR 114 <br />REQUESTOR Stephen Henry /.��C <br />CK 1(BILLING ADDRESS <br /></C�� — fi�ilf: -' - ❑ <br />BUSINESS NAME Henry + Associates Architects <br />VEp <br />PHONE # Ems. <br />916 921-2112 <br />HOME or MAILING ADDRESS 730 Howe Ave, Suite 450 <br />'`161 921-2212 <br />CITY Sacramento <br />STATE CA ZIP 95825 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned properly or business owner, operator or Authorized agent of some, <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 />1 also certify that 1 have prepared this application and that the work to be (o will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DA-rE: <br />PROPERTY/ BUSINESS OWNERILL OPERATORI NLLN.{GER ❑ L1,6TIIER AUTHORIZED AGENT 11 <br />1fAPPGIGINT is nor the BILLINGP,4177) proof of authorization to sign is required Tille <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 lime it is <br />provided to me or my representative. <br />w__ <br />TYPE OF SERVICE REQUESTED: <br />PAYME.N <br />COMMENTS: <br />VEp <br />APR 0 6 <br />2020 <br />SAN <br />JVIRON JOAQUIN CO <br />EUN1y <br />HEALTH ENTAL <br />DEP <br />ACCEPTED BY:7--i t i '/ <br />EMPLOYEE #: <br />ATE: �l <br />ASSIGNED TO: .L <br />EMPLOYEE #: <br />DATE: <br />r <br />I <br />Date Service Completed (N already completed): <br />SERVICE CODE: t" <br />P <br />Fee Amount:_ <br />Amount Paid <br />.L�GI n ri <br />Payment Date „ 2 �, <br />Payment Type Sw-_ <br />Invoice# <br />Checks O 3 <br />RecelvedBv <br />EHE) 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />