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JOSHUA COWELL ELEMENTARY SCHOOL <br />Site Address <br />Direction <br />Street Number <br />City State <br />Ext.Land Use Application #APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor JONATHAN GISH <br />Ext.Business Name TPH ARCHITECTS <br />Home or Mailing Address 519 MCHENRY AVE. <br />12/7/23APPLICANT’S SIGNATURE: <br />Type of Service Requested: Plan Review <br />Employee #: <br />Employee#:Assigned to: <br />Amount Paid <br />Invoice #Payment Type <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />Manteca <br />City <br />Type of Business or Property <br />ELEMENTARY SCHOOL <br />PESTANA AVE <br />Street Name <br />Payment Date <br />/ 2^ H <br />SERVICE REQUEST# <br />95336 <br />Zip Code <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Street Name <br />Zip <br />Owner / Operator <br />MANTECA UNIFIED SCHOOL DISTRICT <br />Facility Name <br />740 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Date Service Completed (if already completed): <br />Fee Amount: $ 0C <br />Date: 12.| Il ( 2-3 <br />Date:|2|(||23 <br />/| <br />]V(n( 2^77^ <br />Received By:y/^-^7/ <br />Phone #1 <br />( ) <br />Phone #2 <br />() <br />Check if Billing Address O <br />Check if Billing Address O <br />Phone # <br />(209) 571-2232 <br />Fax# <br />(209) 571-1936 <br />State QA Zip 95354 <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 wdtk to be performed will be done in accordance with all San Joaquin <br />County Ordinance Codes, Standards. STATE and FEDDIAL <br />\ffoR / Manager <br />Service Code: 523 <br />- <br />Check # , <br />Date: <br />Property / Business Owner Operator/ Manager Oi her Authorized Agent El ARCHITECT <br />If APPLICANT is not the Hilling Part}’, 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 environmentapj^yu^sment <br />information to the San Joaquin County Environmental Health Department as soon as it is available and at Is <br />provided to me or my representative. ^^IVED <br />QEc 1 1 2023- <br />Comments: p|an revjew js fOr a serving line in a new multi-purpose. There is an existing <br />the existing multi-purpose building (no work). Food is prepared in the kitchenng^W^ENTAL n <br />carts, and wheeled to the serving line. No food prep occurs in this new building, onlyEPArtment <br />serving. After serving the hot carts, pans,and serving utensils are returned to the kitchen <br />for cleaning. <br />Accepted By: M <br />C,TY MODESTO