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NEW HAVEN ELEMENTARY SCHOOL Site Address Direction Street Number City State Ext. Ext. Requestor JONATHAN GISH Business Name TPH ARCHITECTS Home or Mailing ADDRESS 519 MCHENRY AVE. APPLICANT’S SIGNATURE: Type of Service Requested: Plan Review Employee #:Accepted By: Employee #:Assigned to: Service Code: Fee Amount: Invoice # SR FORM (Golden Rod)ftEHD 48-02-025 REVISED 11/17/2003 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL Health Department hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. Type of Business or Property ELEMENTARY SCHOOL APN # ^-O^IOCOS AUSTIN RD. Street Name MANTECA City Date: Property/ Business Owner Operator/ Manager Other Authorized Agent El ARCHITECT If APPLICANT is not the BILLING Party, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the San JOAQUIN COUNTY ENVIRONMENTAL Health DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 14600 Street Number Home or Mailing Address (if Different from site Address) Owner / Operator MANTECA UNIFIED SCHOOL DISTRICT Facility Name Amount Pai Check# Street Name Zip Payment Date Phone #2 ( ) Land Use Application #Phone #1 ( ) Check if Billing Address LJ Ext. \ PR oihlC38 San Joaquin County Environmental Health Department SERVICE REQUEST FACILITY ID# P.O SERVICE REQUEST # Check if Billing Address IZJ Phone# (209) 571-2232 Fax# (209) 571-1936 State CA Zip 95354 95336 Zip Code ^*2020 BOS District _ cos CONTRACTOR / SERVICE requestor C|TY MODESTO comments: p|an revjew js for a serving line in a new multi-purpose. There is an existing full kitchen in the existing multi-purpose building (no work). Food is prepared in the kitchen, put in hot carts, and wheeled to the serving line. No food prep occurs in this new building, only serving. After serving the hot carts, pans,and serving utensils are returned to the kitchen for cleaning. Cuco Date Service Completed (if already completed): Payment Type \J Date: Date: p ,l P',E7W Received