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3AN JOAQUIN LOUNI Y ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />School . <br />FACILITY ID # SERVICE REQUEST # <br />5 R eo g (0043 <br />OWNER/OPERATOR <br />Specialized Education Services Inc CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Sierra School of San Joaquin <br />SITE ADDRESS <br />2106 Street Number Direction Cherokee Wi,.eaelil N am e Stockton <br />City <br />95205 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />1 944 Street Number <br />North El Pinal Drive <br />Street Name <br />Crrv Stockton STATE, ZIP ua 95205 <br />PHONE #1 Err. <br />( 209) 933-7015 2262 <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. Ii BOS <br />(209 ) 933-7015 2274 <br />DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LaShonta Netherly CHECK if BILLING ADDRESS X <br />BUSINESS NAME <br />Stockton Unified School District, Child Nutrition/Food Services <br />PHONE # <br />(209 ) <br />Err. <br />933-7015 2262 <br />HOME or MAILING ADDRESS <br />1944 North El Pinal Drive <br />FAX # <br />( ) <br />CITY Stockton STATE Ca ZIP 95205 <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: /t2 DATE: 11/07/2022 <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER OTHER AUTHORIZED AGENT In Child Nutrition, Business ManagE <br /> <br />If APPLICANT is not tile BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the p s erty located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or enviro ssmcnt <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a e it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: (.0i/ILLA.,t,b)„,--b-01,-, fvuv 15 2022 ,41 N 4 Q, , <br /> <br />COMMENTS:,10, <br />L' IseivVIR 0 IN co <br /> <br />A LTH mEN T uNry R ".. A 1_ <br />, MEN T <br />ACCEPTED BY: A on s Ica i a. EMPLOYEE #: DATE: 1 1 / 1 5 / ‘.0.. <br />ASSIGNED TO: A—ED05 /4„; c.._ EMPLOYEE #: ciPt, )_,s DATE: I( / i 5 / a <br />Date Service Completed (if already completed): SERVICE CODE: 0 6 ( PIE: <br />Fee Amount: 4j? (,, Amount Paicd• /2, ,00 Payment Date /1/15:72;-, <br />/ <br />Payment Type iii Invoice # Check # /s7E -.2 72_2____- Recei ed By:44_ <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)