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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST# School riq 000a37Z3I- G &LA24 OWNER / OPERATOR Stockton Unifoed School District ACCEPTED BY: Stockton Unifoed School District CHECK if BILLING ADDRESS FACILITY NAME ASSIGNED TO: FAX# Primary Years Academy (formerly Tyler School) 1944 N. EI Final Drive Date Service Completed ( already completed): SITE ADDRESS I Webster Ave I STATECA Stockton 95240 3830 Street Number Direction Payment Date street Name Cil Z"Code HOME or MAILING ADDRESS (If Different from Site Address) Received By: Sbeet Number Street Name CITY STATE ZIP PHONE 91 Exr• APN M LAND USE APPLICATION N ( 209) 933-7015 2262 PHONE#2T BIDS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Child Nutrition Department CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# COMMENTS: Remodeled Kitchen Facility. Require Inspection and permit to operate. EXT. Stockton Unifoed School District ACCEPTED BY: 20 933-7015 2262 HOME or MAILING ADDRESS ASSIGNED TO: FAX# DATE• 1944 N. EI Final Drive Date Service Completed ( already completed): (209 )933-7016 Cm Stockton STATECA zip 95205 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 FEDERAL laws. //A 2 Z. .3 APPLICANT'S SIGNATURE• Z �� ,/L— DATE: PROPERTY/ BUsINESSOWNER❑ OPERATOR/MANAGER® OTHER AUTHORIZED AGENT /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tette 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. PAYMENT D TYPE OF SERVICE REQUESTED:CID 617 { FEB ?-aH COMMENTS: Remodeled Kitchen Facility. Require Inspection and permit to operate. SANJOAOUINCD ENVIRONMENT HEALTH OEPARTM ACCEPTED BY: EMPLOYEE#: DATE. =/ rr ASSIGNED TO: EMPLOYEE #: DATE• Date Service Completed ( already completed): SERVICE CODE: I E: Fee Amount:S Amount Pal /s Payment Date a r> Payment Type Invoice # Check # Received By: REVISED 11017/2003 L"V n- ( / S 75" 33 0 S �-- .2/;w I� � 2 RM (Golden Rod) 023 nY