Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> School S G -2) <br /> OWNER/OPERATOR <br /> Lincoln Unified School District CHECK If BILLING ADDRESSO <br /> FACIL"NAME Sierra Middle School <br /> SITE ADDRESS 6768 Alexandria Place Stockton 95207 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2010 W Swain Road <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95207 <br /> PHONE#1 E)T• APN# LAND USE APPLICATION# <br /> (209) 953-8700 <br /> PHONE#Z Err. BOS DISTRICT LOCATION CODE <br /> (209) 351-1922 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Rebecca Hall CHECK If BILLING ADDRESS <br /> BUSINESS NAME Lincoln Unified School District PHONE# ExT. <br /> 209 953-8700 <br /> HOME or MAILING ADDRESS 2010 W Swain Road FAX# <br /> CITY Stockton STATE CA ZIP 95207 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> Ass ci to Supe' tendent <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT of Business Services <br /> IfAPPL7CANT 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 TOA QUrN COQ TTY EN'v17ROITi CENTAL HEALTH DEPARTMENT as soon as it is available and at the same a it is <br /> provided to me Or my representative. <br /> TYPE OF SERVICE REQUESTED: 1 ` 'Ica <br /> COMMENTS: <br /> H ANJO,4O�lN Z3 <br /> c <br /> E9CTy0E�� Nay <br /> NT <br /> ACCEPTED BY: r EMPLOYEE#: Zjl DATE: z Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comp ted (If already completed): SERVICE CODE: P 1 O <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 5 <br />