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Frc '640138 Page:3/3 Date: 1014,12OG59:2r AM <br /> -"... ,�...��., �.vaIrrr lair vllr.vlrlrr�lr AH.L J1au1..f ._1r;YAAi AIYA.0\1 <br /> SERVICE REQUEST <br /> BNAME <br /> Business or Properly FACILITY tU A =SERVICE REQUESTq <br /> 12 <br /> RATOR <br /> Tracy Unified School District CHECK It BiLLINn ADDRE$$I X <br /> John C.Kimball High School <br /> � S Lammers Road Tracy n/a <br /> $ Steel Now QiW zin G."G ADDRESS (If different from Site Address) 1875 Lowell Ave All Anne Bell <br /> Street Number <br /> Cm Tracy ...... STATE CA n,.ZIP 95376 <br /> PHONE#1 ET. APN9 LAND USE APPLICATION# <br /> ( 209 ) 830-3200 1 2.L}O - 020 - 002. <br /> PNoNE#2 Exr. SOS DISTRICT LOCAr"CODA <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jason Ellis CHECK if BILLING AbORESS❑ <br /> HusiNass NAMEPHIXVH# En <br /> Lionakis Beaumont Design Group 916 558-1900 294 <br /> HOMa or MAILING APORE98 FAS# <br /> 191919th Street (916 1558-1919 <br /> CITY Sacramento STATE CA zip95814 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or pfoject specific ENVIRONMENTAL IIEALTtt DEPARTMENT hOUrly chargCS Associated with this project Or <br /> 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 is accordance with all SAN JOAQuiN <br /> COUNTY Ordinance Coder,Standards,STATE end FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 0. DATE: rryy/� 2 S �j� <br /> PROPERTY/BUsiNnss OWNER❑ 0"RATOR/MANAGER ❑ y,nERAOTrrORIZROAGENT vl — `� 'r'i /TSD <br /> f/APPLICANT is not the B1LLINGPARTY.proof of atrrfiprteatinn to sign is required T/rre <br /> AUrHO ZAnON TO RELEASE INFORM When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any ad all results, geotechnical data and/of environmcntallsite assessment <br /> information to the SAN JOAQUN COUNTY ENVIRCNMLNTAL HPALTH DEPARTMENT as soon as it is available and at the seine time it is <br /> provided to me or my representative. <br /> TYPE OF SERVILE REQUESTED PAYMENT <br /> CoaMENTS: Alb e0&'j-C S. /� �'g''��- H�'��+ <br /> NOV 2 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> TH DEPARTMEIJT <br /> ACCEPTED By! EMPLOYEE#: DAs' J/ y <br /> ASSIGNED TO: LZ 1 <br /> EMPLOYEE#:SERVICECODE: P)E:t7 DATC // y <br /> Data Service Completed (If already completed): SL3 <br /> Amount Paid Payment Date <br /> Fee Amount:$279 00 ' <br /> P <br /> �� Gheak# b�qD calved By! <br /> aymentTypa Invoice# N(f <br /> sR FP.O MJ(Goldon Rod) <br /> EHD AM2-026 <br /> REVISED 11/17/2003 <br />