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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business <br /> or Property FACILITY ID# <br /> nVICE <br /> REQUEST# <br /> ElementarySchool - Kitchen <br /> L <br /> OWNER I OPERATOR <br /> Lodi Unified School District CHECK It BILLINGADDRESS� <br /> FACILITY NAME Needham Elementary School <br /> SITE ADDRESS 420S. Pleasant Ave. Lodi 95240 <br /> S..,Number r• I n I Street Nems City ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slroal Numher Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (209y 331-7375 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Jennifer Huang CHECK If BILLING ADDRESS <br /> BUSINESS NAME Rainforth Grau Architects PHONE# Exr. <br /> 916)I368-7990 <br /> HOME orMAILINGADDRESS 2101 Capitol Ave., Suite 100 FAX# <br /> ( I <br /> CITY Sacramento STATE CA ZIP 95816 <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 t e rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE-and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATg; o/iA�— <br /> PROPERTY/ <br /> BUSINESS OWNER OPERATOR/NIANAGER THEIR AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY.n,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 I IFALTti 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: Kitchen review EIV <br /> COMMENTS: D <br /> AUG 18 ?020 <br /> HQU <br /> e�NAONMENOUNTy <br /> DEPgR ua AL <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE 6213 DATE: 8-18-20 <br /> ASSIGNED TO: Steven Shih EMPLOYEE#: '7380 DATE: 8-18-20 <br /> Date Service Completed (If already comploted): SERVICE CODE: 523 P i E: 1601 <br /> Fee Amount: 456 Amount P i1e-1 Payment Date Sl <br /> Payment Type Ce Invoice# Check# Recel d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />