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San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />School Warming Kitchen <br />Site Address <br />Street Number <br />City State <br />apn#Ext.Land Use Application # <br />Email BOS District Location CodeExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />ZipCity 95816SACRAMENTO <br />APPLICANT’S SIGNATURE: 4/10/2024Date: <br />ARCHITECT <br />Type of Service Requested: <br />7Comments: <br />PAYMENT CONFIRMATION NUMBER FOR THE AMOUNT OF $486: 179523930 <br />Employee #:Accepted By: <br />Employee#:Assigned to: <br />Service Code:Date Service Completed (if already completed): <br />Payment DateFee Amount: <br />Invoice # <br />SR FORM (Golden Rod) <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 or activity <br />will be billed to me or my business as identified on this form. <br />EHD 48-02-025 <br />03/22/23 <br />Houston Ave <br />Street Name <br />Stockton <br />City <br />745 <br />Street Number <br />SERVICE REQUEST# <br />95206 <br />Zip Code <br />_____________ <br />Payment Type \J <br />Owner / Operator <br />KIPP: Stockton Elementary School <br />Facility Name <br />Requestor <br />__________ROGER ANDRADE <br />Business Name <br />__________HMC ARCHITECTS <br />Home or Mailing Address <br />2101 Capitol Ave #100 <br />Direction__________________ <br />Home or MAILING Address (If Different from Site Address) <br />Street Name <br />Zip <br />Phone#2 <br />() <br />Phone#1 <br />( ) <br />Check if Billing AddressDI <br />Phone# <br />( 916 ) 368-7990 <br />Fax# <br />( )_______ <br />Email <br />roger.andrade@hmcarchitects.com <br />Amount Pai <br />| Check# 1 <br />FlCheck if Billing Address kxJ.................T <br />State ca <br />11 <br />Date: O <br />Oate: <br />| P/E: <br />Received By:/>/ <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 />Property/Business Owner Operator / Manager Other Authorized Agent H <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 above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />San Joaquin County Environmental Health Department as soon as it is available and at the same time it is provided to me or my <br />representative.