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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 OD�U-g S(0 <br /> OWNER I OPERATOR <br /> Stockton Unified School District CNi2CK1fBILLINGADDRESS X <br /> FACIUff NAME TBD <br /> SITE ADDRESS 2111Quaii Lakes Drive Stockton 95207 <br /> Street Number Direction Street Name -CityZJD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1944 N. EI Pinal Drive <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95202 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209)933-7000 108-020-040-000 <br /> PHONE#2 Err, BCS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REctutasToR <br /> Aya Shitanishi CHECK If BILLINGADDRES5 <br /> SUSINEss NAME TETER, LLP PHONE# EiT- <br /> ( 559) 437-0887 2306 <br /> HOME Or MAILING ADDRESS 7535 N. Palm Ave, Ste: 201 FAx# <br /> ( 559)438-7554 <br /> CITY Fresno STATE CA ZIP 93875 <br /> BELLING 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: DATE: 0- 1b-is <br /> PROPERTY 1 BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AuTHomzED AGENT 0 Architect <br /> IfAPPLICRNT is not the BILLINCrPARTY,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 SATs JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and� rrie time it is <br /> provided to me or my representative. C: <br /> 71 <br /> TYPE OF SERVICE REQUESTED: �f SG✓(tet VED <br /> COMMENTS: <br /> le c-t y,9 ru c— SAN S `AN Jp qQ 1 2��9 <br /> GUe54vn , no d� 6err C -fe fe i-a e - co rn H�cr'�'�",i o �,°rte rr <br /> �'f�nrr <br /> ACCEPTED BY: ���Lti GS EMPLOYEE#: DATE: <br /> ASSIGNED TO: O 1 vS,I EMPLOYEE#: DATE- 3 �2 <br /> Date Service Completed (If already completed): SERVICE CODE: I P/E: <br /> Fee Amount: A* Amount Pai t1L ,OD Payment Date 3V�2-zll rr <br /> Payment Type C!� Invoice# Check# ?�j�9'7q��j Rece ved/By: <br /> EHD 48-02-025 p�1d' ' �� `,~ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />