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.r. SERVICE REQUEST AIe r✓(/�G� 1 <br /> Type of Business or Pioperty FACILITY ID# SERVICE REQUEST# <br /> SCHOOL DISTRICT <br /> v � t ( <br /> OWNER/OPERATOR BILLING PARTY <br /> TRACY UNIFIED SCHOOL DISTRICT ( BOB CORSARO — DIR. OF MAINTENANCE) <br /> FACILITY NAME <br /> TRACY JOINT UNION HIGH SCHOOL <br /> SITE ADDRESS EASi <br /> 315 street Number Jire ELEVENTH Street Name Type Suite# <br /> Mailing Address (if Different from Site Address) <br /> 315 E. 11TEI STREET TRACY CA 95376 <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> X09) _ <br /> °iIONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> TRACY UNIFIED SCHOOL DISTRICT— BOB CORSARO — DIRECTOR OF MAINTENANCE <br /> BUSINESS NAME PHONE# Er. <br /> TRACY UNIFIED SCHOOL DISTRICT 20 831-5049 <br /> MAILING ADDRESS FAX# <br /> 315 EAST ELEVENTH STREET 20 831-5572 <br /> CITY TRACY STATE CA ZIP 95376 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLic HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project 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 COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �J <br /> APPLICANT SIGNATURE: �/ l���/PZ�/ DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If AapucANr is not the 81WNG 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 above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D�O/ <br /> COMMENTS: / MENIPAY <br /> JAN 2 6 1999 <br /> SAN JOAQUIN COUNT) <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS10t, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: G J DATE: <br /> ASSIGNED TO: G EMPLOYEE#: 6q& 7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 Q PIE: <br /> Fee Amount: Z 3 q , QD Amount Paid 5/�Q Payment Date <br /> Payment Type Invoice# Check# f �� (��7� Received By: <br />