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SAN JOAQUV- COUNTY ENVIRONMENTAL HEALT- DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail store ) A �(2 L9 (_ �'� <br /> OWNERIOPERATOR Target CHECK If BILLING ADDRESS <br /> FAaurrNAME Target <br /> SITE ADDRESS 280 Spreckels Manteca 95336 <br /> street Number on Street Name c Zi Cada <br /> HOME or MAILING ADDRESS IN Different from Site Address) 50 S 10th Street, Suite 400 <br /> Strael Number S Hama <br /> Cm Minneapolis STATE MN LP 55403 <br /> PHONE#1 E%r. APN# LAND USE APPLICATION# <br /> (612) 761-1505 L�- I -Zt1U �71 <br /> PHONE#2 EXt. BIDS DISTRICT LOCATION C(O�DE <br /> L�t' S IV ILl L4LC-e\ <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS o <br /> BUSINESS NAME PHONE# EX' <br /> HOME or MAILING ADDRESS FA%# <br /> l ) <br /> CITY STATE LP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ItheILLING <br /> S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 7f APPLICANT is noPARTT 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. /� l <br /> TYPE OF SERVICE REQUESTED: (--u—v C� I' 1,cvv a <br /> CDNMEKTs: PAYMENT <br /> RECEIVED <br /> SEP 0 S 2014 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: ,� _ EMPLOYEE M SAMLT TIENT <br /> ASSIGNED TO: ( �/ EMPLOYEE#: DATE: �l <br /> Date Service Completed (N already completed): SERVICE CODE: (� Z PIE: 16 G I <br /> Fee Amount: 43090 I Amount Paid !�39D I Payment Date <br /> Payment Type Invoice# Check# CigS-10 q�(S3� Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />