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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACiLiTY ID # <br />SEROCE REQUEST # <br />School <br />RECEIVED <br />AUG 18 2011 <br />SAN joAQUIN <br />ENV MENTA COUNTY <br />NT <br />P' <br />OWNER I OPERATOR <br />cHECRifBu.0 <br />Stockton Unified School District - Child Nutrition/Food Services Department AmLRm❑ <br />FACUry NAME Special Education Young Adults Program (YAP) <br />SITEADmEss 1541 <br />E. <br />March Lane <br />Stockton 95207 <br />$beat Number <br />Clreullon <br />. Iree1 Na _ e <br />G Zip UtI6 <br />HOME OrlIIlAIL1NG ADDRESS (If Diffemrit from Site Address) <br />933-7016 <br />Street NurnMr <br />StM#t Name <br />CITY STATE zip <br />PHONE #1 ExT. <br />{ <br />APN # <br />LANo USE APPLICATION # <br />PHONE #2 EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE la, QUESTOR <br />REQUESTOR Joni Isturis, Acting Director <br />PAYMENT <br />CHECK Ife I O s® <br />BUSINESS NAME <br />RECEIVED <br />AUG 18 2011 <br />SAN joAQUIN <br />ENV MENTA COUNTY <br />NT <br />P' <br />EXT• <br />Child Nutrition/Food Services Department <br />W <br />933-7015, 2269 <br />HOME or WfLING ADDRESS <br />EMPLOYEE <br />FAX# <br />DATE: klo2hl17 <br />1944 N. EI Pinal Drive <br />SERVICE CODE: <br />( 209) <br />933-7016 <br />01W Stockton <br />STATE CA <br />zIP 95205 <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 DEPARTmEm' 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 SA?IJOAQL11N <br />COUNTY Ordinance Codes, Standards, S' TE. and FEDERAL laws. <br />APPLICANT'S SIGNATURE: s s DATE: <br />PROPERTY I BUSINESS OWNER ❑ F.RaT OR I A-LANAGER IN OTHER AuTtloiuzEo Ac ENT ❑ <br />YAPPLICANT is not the,BJCLAAgP,IRTY. proof of authorization to sigh is regWrett Title <br />ALTHORI ATION 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 anv and ail 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 SERVICEREQIESTED: Twice per year health inspection of kitchen <br />PAYMENT <br />CoMµBNrs: <br />RECEIVED <br />AUG 18 2011 <br />SAN joAQUIN <br />ENV MENTA COUNTY <br />NT <br />ACCEPTED BY: G,1� Q Q <br />l• <br />EMPLOYEE tE: <br />DATE: 117 <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: klo2hl17 <br />Date Sarvlce completed (if already completed): <br />SERVICE CODE: <br />` <br />PIE. <br />V <br />V <br />Fee Amount: UArttount <br />Paid <br />, �J — <br />Payment Date S .Z l - <br />Payment Type L <br />Invoice # <br />Check 11 a q <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rad) <br />REVISED 1 1117/2003 <br />