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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type Business Property <br />FACILITYD # <br />BUSINESS NAME Clark/Sullivan Construction <br />SERVICE REQUEST # <br />High School <br />Public School <br />(—l� <br />COMMENTS: <br />Plans and specifications provided <br />riJopf <br />OWNER / OPERATOR Lincoln Unified School District <br />Ii�PL�`lbYLt'C �I�t µs <br />FAX# <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Lincoln Unified School District, Lincoln High School <br />1 510)510-3055 <br />SITE ADDRESS 6884. <br />STATE CA ZIP 95678 <br />Alexandria Place <br />p pM� <br />Stockton <br />95207 <br />Street Number <br />rectio <br />Street Name <br />EMPLOYEE#: <br />city <br />Vy Code <br />HOME or MAILING ADDRESS (if Different from Site Address) 2010 <br />EMPLOYEE #: <br />West Swain Road <br />Street Number <br />Street Name <br />CITY Stockton <br />STATE CA ZIP 95207 <br />PHONE#1 PTT' <br />APN# <br />LAND USE APPLICATION# <br />(831 ) 3453037 <br />�S <br />Payment Type � � <br />PHONE#2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />(209 ) 953-8700 <br />EHD 48-02-025 �� �j y cc, <br />CONTRACTOR / SERVICE REQUESTOR , <br />REQUESTOR Manuel Jimenez <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Clark/Sullivan Construction <br />TYPE OF SERVICE REQUESTED: Pool Renovation review <br />PHONE# EXT' <br />COMMENTS: <br />Plans and specifications provided <br />916) 338-7707 <br />Home or MAILING ADDRESS 2024 Opportunity Dr, Suite 150 <br />Ii�PL�`lbYLt'C �I�t µs <br />FAX# <br />1 510)510-3055 <br />CITY Roseville <br />STATE CA ZIP 95678 <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 FEDEE law 1 q <br />APPLICANT'S SIGNATURE: '44 DATE: <br />rolec anager, ar u Ivan <br />PROPERTY/ BUs[NESs OWNER❑ OPERATOR/MANAGER ❑ 66ER AUTHORIZED AGENT C on-tpuction <br />IjAPPLICANT is not the B/LUNG PAR proof of authorization to sign is required T 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 environuctual/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 />PqY <br />TYPE OF SERVICE REQUESTED: Pool Renovation review <br />COMMENTS: <br />Plans and specifications provided <br />5 2019/ <br />Ii�PL�`lbYLt'C �I�t µs <br />NV/AQUINCOUNIY <br />MNLTN <br />p pM� <br />Nr <br />ACCEPTED BY: /' _ d-r.�Gs LD <br />l.� <br />EMPLOYEE#: <br />DATE: -1 , — ( S <br />ASSIGNED TO: "� e,� <br />EMPLOYEE #: <br />DATE: -GZ —t g <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 15: 2 <br />Fee Amount: $608.00 <br />Amount Pai <br />&JF <br />Payment Date <br />�S <br />Payment Type � � <br />Invoice # <br />Check # 41CO410371 <br />Recei ed By: <br />EHD 48-02-025 �� �j y cc, <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />