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r\ee <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Elementary School <br />FACILITY ID # <br />iVkAi <br />SERVICE REQUEST # <br />51R.00 2 (9 01 3 <br />OWNER/OPERATOR <br />CHECK if Lammersville Joint Unified School District BILLING ADDRESS <br />FACILITY NAME <br />Evelyn Costa Elementary School Kitchen <br />SITE ADDRESS <br />1675 Street Number <br />South <br />Direction <br />Gobind Blvd. <br />Street Name <br />Mountain House <br />City <br />95391 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 111 <br />Street Number <br />South De Anza Blvd. <br />Street Name <br />CITY STATE ZIP <br />Mountain House CA 95391 <br />PHONE #1 Exr. <br />( 209) 836-7400 <br />APN # <br />20906053 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Wesley King CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Ni <br />PHONE <br />ichols, Melburg & Rossetto <br /># EXT. <br />(530 ) 222-3300 <br />HOME or MAILING ADDRESS <br />300 Knollcrest Drive <br />FAX # <br />(530) 222-3538 <br />CITY Redding STATE ZIP CA 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 ENVIRONMEN'I'AL 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, ST ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER!: OPEIFtAl R / MANAGER 0 <br /> <br />DATE: 11/18/2022 <br /> <br />OTHER AUTHORIZED AGENT UI Principal Architect <br /> <br />If APPLICANT is not the BILLING PARTY, 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. <br />i r. <br />TYPE OF SERVICE REQUESTED: <br />fi :2 ill <br />CC:6/1/ <br />COMMENTS: <br />4 <br /> <br />1 ,,,, Review of plans for the Evelyn Costa Elementary School Kitchen (new construction) NOV R . zu; <br />'NJoAr) Hew/R e, LIN cot, ALN D N/WE-Nrs-'1 <br />EpA R 7.4., <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 11-18-22 <br />ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 11-18-22 <br />Date Service Completed (if already completed): SERVICE CODE: 61 PI E: 1601 <br />Fee Amount: 468 Amount Paid *z/6„s. op Payment Date yi sr-72 <br />Payment Type Invoice # Check # ,2 )3, Received By: 676----- <br />Ty <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003