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San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Owner / Operator <br />Jefferson School District <br />Facility Name Corral Hollow Elementary School <br />Site Address <br />Direction <br />City Tracy 95377 <br />Ext.Land Use Application # <br />209.836.3388 <br />Ext.BOS District Location Code <br />Requestor <br />Ext.Business Name PJHM Architects 949.496.6191 <br />Home or Mailing Address 24461 Ridge Route Dr, #100 <br />) <br />City ZipLaguna Hills 92653 <br />12/07/2020APPLICANT’S SIGNATURE: <br />Architect <br />Type of Service Requested: <br />Comments: <br />Employee#:Date:Accepted By: <br />Employee#:Date:Assigned to: <br />Fee Amount: <br />SR FORM (Golden Rod) <br />Phone#2 <br />( ) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Type of Business or Property <br />K-8 School <br />APN # <br />253-380-030-000 <br />Coriander St and Fargo Court <br />Street Name <br />Tracy <br />City <br />Phone #1 <br />( ) <br />1219 <br />Street Number <br />95377 <br />Zip Code <br />Whispering Wind Drive <br />_________________________Street Name <br />Zip <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />_________CONTRACTOR / SERVICE REQUESTOR <br />Kenneth J Podany <br />Service Code: r <br />State <br />CA <br />Date Service Completed (if already completed): <br />4^ <br />Payment Type Invoice# <br />SERVICE REQUEST# <br />Check if Billing Address D <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 />lien®* oj Y\(x\ , <br />Phone# <br />J____1 <br />Fax# <br />( <br />CA <br />Check if Billing Address 0 <br />Az-_______________ <br />Amount Paitf^ <br />| check# 7/// <br />I also certify that 1 have prepared this application and that theyiork to be performed will be done in accordance with all San JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE andXEDERALyws. <br />-------------------- Date: <br />Property / Business Owner Operator / ManaC^r O Other Authorized Agent 0 <br />If Applicant 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 Joaquin County Environmental Health Department as soon as it is available andjit the same time it is <br />provided to me or my representative. —-------------------------------------------------------------- <br />^Nr <br />______ p,f lfrO| <br />Payment Date /2/ <br />Received By: