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DocuSign Envelope ID:48C187D3-36AC.-41A3-8FDB-B5FO14EB793D <br /> SAN d UAQU IN q—UUN'I'y C,N v IRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#�� � SERU,IF�,REQUEST# <br /> School - Food Service <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Aspire Public Schools <br /> FACILITY NAME Aspire PUNIC Schools <br /> SITE ADDRESS 1930 south 0Street Stockton 95206 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1001 22nd Avenue,Suite 100 <br /> Street Number q Sheet Name <br /> CITY STATE Zip <br /> 94606 <br /> Oakland <br /> PHONE#1 Exr' APN# CA94606 <br /> USE APPLICATION# <br /> ( 510 )549-68a4 <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Aspire Stockton New K-5 Incubator CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Exr' <br /> Aspire Public Schools <br /> HOME or MAILING ADDRESS FAX# <br /> 1001 22nd Ave, Suite 100 ( ) <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 JOAQUI N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �j ems. >< 8/5/2020 DA'L'E: <br /> PROPERTY/BUSINESS OWNER❑X OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O CFO <br /> IfAPPLiCANT is not the BILLING PAR7P.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 ant the same time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: IIIXl/1 <br /> COMMENTS: elvvOAUGOQ11 <br /> SANT vA UTAICOU <br /> NEALTHDE ARTML <br /> Nl <br /> oTy <br /> ACCEPTED BY: f EMPLOYEE M 2, DATE: /6 <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P/E: j <br /> Fee Amount: Amount Paid )a,6Z) Payment Date <br /> Payment Type ti Invoice# Check# / ZZq g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />