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SAN JOAQui N LINTY ENVIRONMENTAL HEALTH 1 ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />RECLmiwn <br />FACILITY ID # <br />SERVICE REQUEST # <br />School <br />PHONE# <br />209 <br />(� <br />SIF - U J �3 <br />OWNER/ OPERATOR <br />FAX# <br />Manteca Unified School District <br />CHECK If BILLING ADDRESSEI <br />FACILITY NAME <br />( <br />Manteca High School <br />CITY Manteca <br />SITE ADDRESS 450 <br />East I <br />Yosemite <br />Manteca <br />95336 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />20 <br />Payment Typedlick-)Invoice <br />Street Number <br /># <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Err. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( 1 <br />SOS DISTRICT <br />11 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Aaron Bowers <br />RECLmiwn <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEManteca Unified School District <br />School campus <br />PHONE# <br />209 <br />Ezr. <br />481-3287 <br />HOME or MAILING ADDRESS <br />FAX# <br />2271 W Louise Ave <br />ACCEPTED BY:C '�N Tvzll <br />( <br />1 <br />CITY Manteca <br />STATE CA <br />zip ..337 <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 DEPARTMFNT 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, S T+andERA laws. <br />APPLICANT'S SIGNATURE: DATE:PROPERTY/ BUsINEsS OWNER❑ OPERATI OTHER AUTHORIZED AGENT <br />1f APPLICAAT 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. PAYMpatv <br />TYPE OF SERVICE REQUESTED: <br />RECLmiwn <br />COMMENTS: Plan review of new pool for Manteca High <br />MAK 0 3 2010 <br />School campus <br />SAN JOAQUIN <br />EAMR COUNTY <br />HEAITFiDEFrART <br />NT <br />ACCEPTED BY:C '�N Tvzll <br />EMPLOYEE # <br />�: DATE: 2-0 <br />ASSIGNED TO: V \qQ] V -"1 <br />EMPLOYEE #: <br />DATE: '%J n l` <br />Date Service Completed (If already completed): <br />SERVICE CODE: 523 <br />P 1 E: (.f1 <br />Fee Amount: $608.00 <br />Amount PaidJ(p <br />Payment Date <br />3 <br />20 <br />Payment Typedlick-)Invoice <br /># <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/172003 <br />