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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# LUSD District Warehouse s200 0 15f"`, OWNER I OPERATOR Lammersville Unified School District CHECK if BILLING ADDRESS FACILITY NAME LUSD District Warehouse SITE ADDRESS 16555 S Von Sosten Rd Tracy, CA 95304 Street Number Direction I Street Name Cit ZIP Code HOME Or MAILING ADDRESS (If Different from Site Address) 11 1 S. De Anza Blvd Street Number Street Name CITY Mountain House, CA 95391 STATE ZIP PHONE#1 EXT APN# LAND USE APPLICATI N# ( ) 209 836 7400 20914009 PHONE#2 EXT, BOS DISTRICT L.OcATIoI.0 E ( ) 'J CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Todd Tillman CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. II Roebbelen Contracting Inc 9169394000 I HOME or MAILING ADDRESS FAX# ` 1241 HAWKS FLIGHT COURT ( ) CITY EL DORADO HILLS. CA 95762 STATE ZIPA, BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent 1;1'4 & A acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with t ' roiect or� activity will be billed to me or my business as identified on this form. /Z also certify that I have prepared this application and that the work to be performed will be done in accordance with �pAQUIN COUNTY Ordinance Codes, Standards, STATE and DE L laws N"�klk 1N C'U � �A(rHO�p APPLICANT'S SIGNATURE: _fj " ,� DATE: 7 ARrMFH r PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT cT✓:, / ` ��d,r�f �,�, If APPLICA14T is not the BILLING PARTY,Proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the same time It IS provided to me Or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: v7/ Fee Amount: " Amount Pai 'i Payment Date v oCI� Payment Type Invoice# Check# Received By: G�- C2�gS.�- 76 j 7 Zo s�ur� OEC D/08802-025 /-,1L /,/-.o— '✓ �� A�ORM(Golden Rad)