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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 44aI'l - MSUNK4f I FA 001 b -3S12oo1s'(,CC (-C <br /> OWNER/OPERATOR <br /> Family Dollar Store, INC. CHECK If BILLING ADDRESS <br /> FACILITY NAME Family Dollar <br /> SITE ADDRESS Jackson Ave. Escalon 95320 <br /> 2043 <br /> Street Number I Direction I Street Name city Zip Code <br /> — <br /> HOME or MAILING ADDRESS (If Different from Site Address) Manroe Rd. <br /> 10301 Street Number Street Name <br /> CITY Matthews STATE NC ZIP 28105 <br /> PH0NE#1 EXT_ APN# LAND USE APPLICATION# <br /> ( 704)847-6961 227-260-31 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) ca �cc, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Fahmida Rashid, Authorized Agent CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Permit Advisors PHONE# EXT. <br /> 310 275-7774 <br /> HOME or MAILING ADDRESS 8370 Wilshire Blvd., STE 330 FAX# <br /> I ) <br /> CITY Beverly Hills STATE CA ZIP 90211 <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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> pp � <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER 13 OTHER AUTHORIZED AGENT) lAyl � <br /> 1f APPL/CANT 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 environmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablit is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: OCCA R M <br /> COMMENTS: MAR 15 2018 <br /> N/� � <br /> R (:NVIRONNI'ENTALHEAL H <br /> RUSH !' ?,916 DEPARTMENT <br /> h ''/R G/N <br /> FACTy�'JAI 1-0 <br /> M <br /> ACCEPTED BY: EMPLOYEE M DATE: 3 I I S I l y <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Compl'e&d (if already ompleted): SERViCECODE: s L3 PIE: I LQ D <br /> Fee Amount: ( &bLi taU Amount Pal UVU4 oD Payment Date 3Z/ g <br /> Payment Type Invoice# Check# g�,u Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />