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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH RPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# rSERVICE REQUEST# <br /> O <br /> Retail 7 y <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> 99 Cents Only Stores <br /> FACILITY NAME <br /> 99 Cents Only Stores <br /> SITE ADDRESS 2888 W Grant Line Road Tracy 95304 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4000 Union Pacific Avenue <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> Commerce CA 90023 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (323 ) 980-8145 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Micheal Zavilla CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> 99 Cents OnlyStores LLC - <br /> HOME Or MAILING ADDRESS400n Union Pqrffir <br /> FAX# <br /> ( ) <br /> CITY Commprrp STATE CA ZIP 2 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: wi oon1.5 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR Construction Manager <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: t t'd RECEIVE[) <br /> COMMENTS: I FEB 10 2015 <br /> SM!JOAQUM COU <br /> WIY <br /> HEATH I)ARTT..MEHT. <br /> ACCEPTED BY: rf CC EMPLOYEE#: DATE: ihil <br /> y— <br /> ASSIGNED TO: EMPLOYEE#: (Vr� DATE: O <br /> Date Service Completed (if already completed): SERVICE CODE: `' i E: L7 <br /> Fee Amount: 390,1j(� Amount Paid �r Payment Date <br /> Payment Type v---- Invoice# Check# ��(o� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />