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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Public High School <br /> OWNER/OPERATOR <br /> Lammersville Unified School District CHecK if BILLING ADDRESSE] <br /> FACILI7YNAME peter Hansen-Elementary School <br /> SITE ADDRESS .1400 S . :Durant Terrace <br /> FMt.:House. 17P,22 1 <br /> Street Number Dlrectlon Street Name CI <br /> ty HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION#' <br /> ( ) (209) 836-740.0- 20945030 <br /> PHONE#ZT• BOS DISTRICT- . LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR WesleyKing g CHECK if BELLING ADDRESS 1 <br /> $USlNE55NAME Nichols Mel.bur R <br /> g & ossetto PH' <br /> ONE# 530 222-330 <br /> HOME Or MAILING ADDRESS 300 KnoI[crest Drive FAx# <br /> )( )530 222-3538 <br /> ( . <br /> CITY Redding STATE CA ZIP : 96002 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site.and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on.this form. <br /> I also certify that I have prepared this application and that the work to be rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA-F and FEDERAL law . <br /> APPLICANT'S SIGNATURE: DATE: -05.24.201'7 <br /> PROPERTY/BUsmss OWNER❑ OPERATOR' .aANAGER OTHER AUTHORIZED AC$NTO .Architect <br /> IfAPPLICRNT is not theBILLINGGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION 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 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. p A <br /> TYPE OF SERVICE REQUESTED: .-P,ublic School Kitchen Plan Review / FG,- NT <br /> COMMENTS: <br /> . ''�•r 1#14Y <br /> H E 4! 4917 <br /> 7 Q, Coo <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: If:;,,�S f <br /> Date Service Completed (if already completed): SERVICE CODE: �� P 1 E: <br /> Fee Amount: Amount Pai Payment Date — <br /> t 7 4)D ; <br /> Payment Type Invoice# Check# -53.'_ . . Recei ed By: <br /> 4 <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 5R FORM(Golden Rod) ! <br />