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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# REQUEST# <br /> Public Elementary School ::] :::ESERVICE <br /> C0$12cl <br /> OWNER/OPERATOR <br /> Lammersville Unified School District CHECK If BILLING ADDRESS❑ <br /> FACILITYNAME Julius Cordes Elementary School & Professional Development Center (PDC) <br /> SITE ADDRESS 296 E Parco Avenue Mt. House95391 <br /> Street Number Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#; (209) 836-7400 aPN# 20945038 LAND USE APPLICATION# <br /> PHONE ICI En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Wesley King CHECK if BILLING ADDRESS� <br /> BUSINESS NAME Nichols Melburg & Rossetto PHONE# 530 222-3300 <br /> HOME Or MAILING ADDRESS 300 Knollcrest Drive Paz# )(530) 222-3538 <br /> CITY Redding STATE CA zIP 96002 <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- Tformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, SG T,i.E„and F�De�w . <br /> APPLICANT'S SIGNATURE: 4; <br /> Dnrec 05.24.2017 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR .TANAGER OTHER AUTHORIZED AGENT Architect <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. P <br /> TYPE OF SERVICE REQUESTED: Public School Kitchen Plan Review dQFC T <br /> 11 oFft- <br /> COMMENTS: <br /> OCT 21 <br /> JI ?019 <br /> NEACeivVIRDNM ODUN <br /> �OFpgRNM�� <br /> ACCEPTED BY: I IIIA l�n I/t :l EMPLOYEE#: DATE: IO •/1 <br /> ASSIGNED TO: 'A Ae EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P I E: l O <br /> Fee Amount: Amount Pal Payment Date /D /9 <br /> Payment Type Invoice# Check# 7 <br /> ,� Rece ved By: <br /> EHD SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11/17/2003 <br />