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SOSIbs?) <br /> a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Store -103A2 (�t0 <br /> OWNER/OPERATOR <br /> Target CHECK If BILLING ADDRESS <br /> FACILITY NAME Target <br /> SITE ADDRESS 2800 Naglee Rd. Tracy 95304 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EaT' APN# LAND USE APPLICATION# <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Taylor Conterno CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME Glassman Planning Associates PHONE# Ear' <br /> 310 781-8250 5 <br /> HOME or MAILING ADDRESS 1111 Sartori Ave FAX# <br /> "I Torrance STATE CA ZIP 90501 <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: %QrfpB2 C'51mt u DATE, 3/26/21 <br /> PROPERTY/BUSINESS OWNERO PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® AgentforTarget <br /> IfAPPL/CANT is not the BILLING PAR Tv 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. P <br /> TYPE OF SERVICE REQUESTED: EC T <br /> COMMENTS: <br /> PUU4 s MAR3010 70?1 <br /> HEq HD iA MrA NTY <br /> ACCEPTED BY: �f' �Ju e/�0 EMPLOYEE DATE: i. -Uo-7 I <br /> ASSIGNED TO: 1�(Pl a Y EMPLOYEE#: DATE: - /10 7�( <br /> Date Service Completed (if already completed): SERVICE CODE: �22 P 1 E: '-'�J <br /> Fee Amount: (,�(� i Amount Pai ,W Payment Da/te 1 <br /> Payment Type isi, I Invoice# Check# ' g�j$ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> CL <br /> REVISED 11/17/2003. <br />