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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SCHOOL SQo0 gC3 I I I <br /> OWNER I® <br /> ASPIRE PUBLIC SCHOOLS CHECK If BILLING ADDRESS <br /> FACILITY NAME ASPIRE STOCKTON ELEMENTARY <br /> SITE ADDRESS 1605 E MARCH LANE STOCKTON 95210 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1001 22ND AVENUE <br /> Street Number Street Name <br /> CITY OAKLAND STATE CA zip 94606 <br /> PHONE#i En. APN# LAND USE APPLICATION# <br /> (510 )434 5000 1 096-140-49 AND -48 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MARTY KAUFMAN <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME KAUFMAN CONSTRUCTION INC PE# EXT. <br /> (?1%385 385 6534 <br /> HOME Or MAILING ADDRESS 733 LORING AVENUE FAX# <br /> CITY CROCKETT STATE CA zip 94525 <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 per vfined ' e done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards�td DERAL law <br /> APPLICANT'S SIGNATURE: F DATE: 3/24/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BILLING PAR TP 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*A <br /> ne time it is <br /> provided to me or my representative. ME <br /> TYPE OF SERVICE REQUESTED: Q 4."L LIL VE p <br /> COMMENTS: APR 06 <br /> Z01? <br /> �G� tL'EYd�'ltZ P (0.✓v5 SANJOgQU1N <br /> NfgLTHiQ AR M NT <br /> ACCEPTED BY: �,��-C1 �,� EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Cj'�3 PIE: cool <br /> Fee Amount: 6 Amount Pai Payment DatelD ZZ <br /> Payment Type 'S0.— Invoice# Check# e) Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �` V ��—J <br />