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BROCK ELLIOTT ELEMENTARY SCHOOL Site Address Street Number City State Ext.Land Use Application #APN # Ext.BOS District Location Code CONTRACTOR / SERVICE REQUESTOR Requestor JONATHAN GISH Ext.Business Name TPH ARCHITECTS Home or Mailing Address 519 MCHENRY AVE. APPLICANT’S SIGNATURE: Type of Service Requested: Plan Review Employee#: Employee #:Assigned to: Service Code: 4^- 523 Payment DateAmount Paid Invoice # SR FORM (Golden Rod)EHD 48-02-025 REVISED 11/17/2003 Type of Business or Property ELEMENTARY SCHOOL Manteca City Stonum Lane Street Name 1110 Street Number 95337 Zip Code Street Name Zip Direction _______________ Home or Mailing Address (if Different from site Address) San Joaquin County Environmental Health Department SERVICE REQUEST FACILITY ID # Owner / Operator MANTECA UNIFIED SCHOOL DISTRICT Facility Name Phone #2 () 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 FHDERAL laws. B Phone #1 ( ) Check if Billing Address O Date: |Z|lt|23 Date: 11(23 ,| p;E:/\Qg) \ Received By: J / / Phone # (209) 571-2232 Fax# (209) 571-1936 State QA Zip 95354 Date: 12/7/23___________ Property / Business Owner Operator /Manager Other Authorized Agent El ARCHITECT If APPLICANT is not the Hilling Party, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 tinie >*is provided to me or my representative. comments: p|an review is for a serving line in a new multi-purpose. There is an existing full'-fetehfer)’ igggj the existing multi-purpose building (no work). Food is prepared in the kitche^AP^mhot carts, and wheeled to the serving line. No food prep occurs in this new builc^^f^^^ry serving. After serving the hot carts, pans,and serving utensils are returned to for cleaning. Accepted By: 5>V iGUfIC M ■ | Check# SERVICE REQUEST# Check if Billing Address D C|TY MODESTO Date Service Completed (if already completed): Fee Amount: $48^-^® Payment Type