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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Walgreens Ir 1 -S4'QG3-13.9 <br /> OWNER I OPERATOR <br /> Walter Hocutt CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Walgreens <br /> SITE ADDRESS NE Farmington Rd and E Mariposa Rd Stockton 95205 <br /> Street Number Direction Street Name City Zip Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) 151 E. 3rd Avenge <br /> Street Number Street Name <br /> CITY Sart Mateo STATE CA ZIP 94401 <br /> PHONE 41 EXT. APN# LAND USE APPLICATION# <br /> s 6 ) 689-5073 173-040-77 <br /> PH44E#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR <br /> Frank Poss CHECK IfBILLINGADDRE55 <br /> BUSINESS NAME PHONE# EXT. <br /> PSI 51 434-9200 11 <br /> HOME or MAILING ADDRESS FAX# <br /> 4703 Tidewater Ave.Suite B 151 1434-7676 <br /> CITY Oakland STATE CA ZIP 94601 <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 busi i46tified on this form. <br /> I also certify that I have prepar is applicati ;'and that the rk to be p armed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Code tandards STAT and EDE aws <br /> APPLICANT'S SIGNATURE: DATE; (b 1 Z !t <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a C-O'�-'S I L <br /> If A PLIC'ANT 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. <br /> TYPE OF SERVICEREQUESTEO:UST in place closure PAYMENT <br /> COMMENTS: <br /> OCT 21 2011 <br /> SAN JOAQUrN cDUN7Y <br /> EW R O N M El(TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 10/4 <br /> ASSIGNED TO: t - EMPLOYEE#: DATE: <br /> Date Service Comple&dfif already corn ed): SERVICE CODE: / .3 PIE: <br /> Fee Amount: Sb 0---) Amount Paid �-�'�` �� Payment Date �� <br /> Payment Type Invoice# Check# -363L Received y: - <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 (e <br /> F <br />