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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 5 RVICE REQUEST# <br /> Ne sC6,- rl 2b IS--4 <br /> OWNER/OPERATOR <br /> Housing Authority of the County of San Joaquin / KIPP Norcal CHECK if BILLING ADDRESS <br /> FACILITY NAME KIPP Stockton Middle School <br /> SITE ADDRESS 742Dallas Ave. Stockton CA 95206 <br /> Street Num bar I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1000 Broadway, Suite 460. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Oakland CA 94607 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510 )914 0481 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Milan Ninkovic CHECK If BILLING ADDRESS <br /> BUSINESS NAME KIPP Norcal PHONE# EXT. <br /> 510 1 9140481 <br /> HOME or MAILING ADDRESS FAx# <br /> 1000 Broadway, Suite 460. <br /> ( ) <br /> CITY Oakland STATE CA Zip 94607 <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 ENv RoNmENTAL 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 1 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: 4"A—:�A— DATE: T�09/08/21 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT Director of Facilities <br /> IfAPPLICANT 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 availablea[I�L[he same time it is <br /> provided to me or my representative. y <br /> TYPE OF SERVICE REQUESTED: ( J.0 c 0 C( �� �►/ <br /> COMMENTS: <br /> P-edl {�� hFF 119.4 1lv <br /> 320?� <br /> ACTyDFPgR��)-Y <br /> ACCEPTED BY: CLC .uCip <br /> EMPLOYEE#: DATE: cl <br /> --Lr71 ; <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J 1 PIE: <br /> 7 <br /> Fee Amount: Amount P q- D� Payment Date <br /> Payment Type " Invoice# Check# 32, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />