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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> �} <br /> Grocery ^wla V Tc-��S' 0677 <br /> OWNER I OPERATOR <br /> Safeway Inc. CHECK If BILLING ADDRESS <br /> FACILITYNAME Safeway #2600 <br /> SITE ADDRESS 1801 w. lith Street Tracy 95376 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1371 Oakland Blvd Suite 200 <br /> Street Number Street Name <br /> CITY walnut Creek STATE CA ZIP 94546 <br /> PHONE#I EXT' APN# LAND USE APPLICATION# <br /> (209 ) 830-2950 23217024 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Clarence Almonor ClarenceA@c-p.com CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> Cuhaci & Peterson Architects 407 661-9100 <br /> HOME or MAILING ADDRESS 1925 Pros ect Ave. FAx <br /> p (407 ) 661-9101 <br /> CITY Orlando STATE FL ZIP 32814 <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 appli anon and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® permitting Coordinator <br /> If APPLICANT 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: h R ), <br /> COMMENTS: t ✓UAi FQ <br /> �iIITr '1 <br /> a 11f P1av) CV1QC� D ` ?01� <br /> AFM <br /> ACCEPTED BY: EMPLOYEE#: DATE: /9- 2-7- <br /> 2 - / <br /> ASSIGNED TO: EMPLOYEE#: DATE: /,- ,P-7- J <br /> Date Service Completed (if already completed): SERVICE CODE: C,-D;?�I PIE: <br /> Fee Amount: t L Amount Pal Tr ��,T Payment Date (p <br /> Payment Type Invoice# Check# /el Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />