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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> Grocery �c� ����� <br /> OWNER/OPERATOR <br /> Safeway, Inc. CHECK if MILLING ADDRESS❑ <br /> FACILITY NAME Safeway #2600 <br /> SITEADDRESS 1801 ytij 11th Street <br /> Tracy 95376 <br /> Street Name <br /> Street Numher Direction <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Cit Zip code <br /> Street Num Ger Street Name <br /> CITY <br /> STATE Zip <br /> PHONE#1 ExT. } <br /> A <br /> N# LAND USE APPLICATION# <br /> (209 ) 830-2950 32-170-24 ` <br /> PHONE 92 EXT. BOS DISTRICT LOGAnON CODE f] <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REptJESTOR Debi Plaisance Debip@c-p.com <br /> CHECK If BILLING ADDRESS i <br /> BUSiNEss NAME Cuhaci & Peterson Architects PHONE# Em <br /> 407 643-2347 <br /> HOME orMAILING,ADDRESS 1925 prospect Ave. FAx# <br /> 1407 % 661-9101 <br /> CITY Orlando STATE FL Zip 32814 <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 business as ideniified on this form. <br /> I also certify that I have prepared this application and that the work formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FE aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGEN <br /> IfAPPLICANT is not the BILLING PART proof of authorization to sign is requir Ti <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 SERVICE REQUESTED: V:60d RECEIVE[I <br /> COMMENTS: SEP 15 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: 1 ' EMPLOYEE#: DATE: �_I✓ /G <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: I O <br /> Fee Amount: C, Amount Paid '-11-7 <br /> , C�O Payment Date Cl S <br /> Payment Type C Invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 # <br /> r <br /> k <br />