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SAN JOAQUIN rbUNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SCHOOL FOOD SERVICES <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> TRACY UNIFIED SCHOOL DISTRICT <br /> FACIUTYNAME KIMBALL HIGH SCHOOL CAFETERIA <br /> SITE ADDRESS 3200 JAGUAR RUN TRACY 9 5 3 7 7 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 830-3255 1202 '2-c{'O— o2x—Ce <br /> PHONE#2Ext. BOS DISTRICT LOCATION CODE <br /> (209 ) 832-3255 4070 -5 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR et—/"t 0" r �NSr CH GADDRESS <br /> BUSINESS NAME C' G PHONE# Ex , <br /> HOME or MAILING ADDRESS - r L \O 4A-A V ,S`7— FAx# <br /> t G J� ( ) <br /> �J STATE ZIP C1J 5-3,0 <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 DFPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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: 1 ei DATE: 09/14/09 <br /> PROPERTY/BDsINESSOWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT[3JRBAN ERNST DESIGN GROUF <br /> If APPLICANT is not the Bat/NG 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 /> TYPE OF SERVICE REQUESTED: 000 IOL k') CPAII <br /> COMMENTS: C " RECEIVED <br /> SEP 18 2009 <br /> SAN JOAQUIN COUNTY <br /> EWRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 0� v G I EMPLOYEE M O 3 Z Ir DATE: l / �-/O <br /> t- <br /> ASSIGNEDTO: OA EMPLOYEEM WODATE: 9tp-toy' <br /> Date Service Completed (if already completed): I SERVICE CODE: s2� PIE: <br /> Fee Amount: 3 SFS Amount Paid l-5 _ Payment Date a-)r <br /> Payment Type t/ Invoice# Check#�Ty�' 1L-a[f g5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />