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' SAN JOAQUTAUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> tType of Business or Property FACILITY ID I SERVICE REQUEST# <br /> Walgreens 3,33 g <br /> ' <br /> OWNER/OPERATOR <br /> Walter Hocutt CHECKIf BILLING ADDRESS <br /> FACILITY NAME <br /> Walgreens <br /> ' SITE ADDRESS NE Farmington Rd and E Mariposa Rd Stockton 95205 <br /> street Number I Dlractlon I Street Name CRY <br /> Zi Cada <br /> HOME Or MAILING ADDRESS (N Different from Site Address) 151 E. 3rd Avenue <br /> ' Street Number Street Nam <br /> CITY San Mateo STATE CA 71P 94401 <br /> ' PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (6 ) 689-5073 173-040 <br /> PHONE#2 E". BOS DISTRICT LOCATION CODE <br /> ' CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Frank Poss <br /> ' CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E%. <br /> PSI 51 434-9200 11 <br /> HOME or MAILING ADDRESS' (51 )434-7676 4703 Tidewater Ave.Suite B <br /> CITY Oakland STATE CA ZIP 94601 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 bu!s!wse� itified on this form. <br /> 1 also certify that I have prepays applicati sand that th!,wdrk to be p ortned will be done in accordance with all SAN JOAQUIN <br /> ' COUNTY Ordinance CodesC,landards,STAT and DE aws <br /> APPLICANT'S SIGNATURE: - DATE: to <br /> ' .. try PROPERTY/BUSINESS OWNER OPERATOR/M. .. ANAGER ❑ OTHER AUTHORIZED AGENT K9 cv�s✓ l <br /> If APPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 SERVICE REQUESTED:UST In place Closure <br /> COMMENTS: <br /> 1 <br /> ' ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> ' Date Service Completed (if already completed): SERVICE CooE: PIE: <br /> Fee Amount: Amo aid Payment Date Ir <br /> Payment Type Invoice# Check# Received By: <br /> tEHD 48-02-025 <br /> REVISED 11/17/2003 / /^ SR FORM(Golden Rod) <br /> /� � [/,,,_ !Y A� <br />