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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> School �-17F v 5z <br /> OWNER/OPERATOR <br /> Lincoln Unified School District CHECK If BILLING ADDRESS <br /> FACILITY NAME Lincoln Elementary School <br /> SITEADDRESS 818 West Lincoln Road Stockton 95207 <br /> Street Number I Direction street Name Citv 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 ) 953-8716,Attn: Katey Talbot C)r-7 — -i(0 -- C> v <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) G'( 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jay Monnin CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Lionakis Beaumont Design Group, Inc. 916 916-558-1900 <br /> HOME or MAILING ADDRESS 1919 19th Street FAx# 916-558-1919 <br /> (916) <br /> CITY Sacramento STATE CA zIP 95814 <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,STATEnd F RAL laws. <br /> APPLICANT'S SIGNATURE: DATE:� > ! <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C)- 7 F,t c-( LJ-VN <br /> COMMENTS: RECE`V <br /> SSP 2 ►� 2p01 <br /> SAN���oNIMENT EN <br /> ACCEPTED BY: [✓>�_ t v E( (�._ EMPLOYEE#: () �� Z 4ArrI`t�G? L� 1 <br /> ASSIGNED TO: �—LO I--1(4S 0-k�.�—L EMPLOYEE#: 3(, DATE: 'i 'Z.7( C-7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: (�p <br /> Fee Amount: $294.00 Amount Paid $�C�If. D C) Payment Date 13 <br /> Payment Type Invoice# Check# l f� O Received By: 2 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />