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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Elementary School SC, OQ<S 1 zi� <br /> OWNER/OPERATOR <br /> Manteca Unified School District CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> French Camp Elementary School <br /> SITE ADDRESS 4th-Street French Camp 95336 <br /> Street Number I DirectionStreet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 179 Street Number Street Name <br /> CITY STATE ZIP <br /> Manteca CA 95336 <br /> PHONE#1 EXT. APN# `(1 i 13 LAND USE APPLICATION# <br /> (209 ) 825-3200 See attac eList <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C C^ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MCR Engineering CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> MCR Engineering 209 239-6229 <br /> HOME Or MAILING ADDRESS FAx# <br /> 1242 Dupont Court ( ) <br /> CITY Manteca STATE CA ZIP 95336 <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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: A..&"46`"^Oh DATE: 1/4/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑✓ Civil Engineer <br /> If APPLICANT is not the BILLING PARTY,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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:eWTS-& Nitrate Loading Study Plan Check 3 <br /> COMMENT'S: < ) ' t J 1?E. <br /> 8 <br /> ✓0 <br /> gQVi <br /> ACCEPTED BY: L L— EMPLOYEE#: ' <br /> ASSIGNED TO: S S EMPLOYEE#: DATE: '77X/d J <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 PIE: a�p <br /> Fee Amount: b Amount Paid bob.� Payment Date I <br /> Payment Type Invoice# Check# 4(�, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />