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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 7 <br /> SERVICE(REEQUESST_# <br /> Retail �� �� I-0 L ?II )- `I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Family Dollar Inr <br /> FACILITY NAME <br /> Family Dollar#31867 <br /> SITE ADDRESS <br /> 2118 Slr8 Number DirecJction Airport Way Street Name Stocktoncit 95 O�ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) Volvo Pkwy, Licensing <br /> 500 Street Number Street Name <br /> CITY STATE ZIP <br /> Chesapeake VA 23320-1604 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 757 ) 321-5000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Amy Smalls CHECK If BILLING AODRESSO <br /> BUSINESS NAME PHONE# E%T. <br /> Family Dollar, Inc 7321-5369 <br /> HOME or MAILING ADDRESS Fax# <br /> 500 Volvo Pkwy ( ) <br /> CITY Chesapeake, STATE VA ZIP <br /> P 23320-1604 <br /> BILLING ACKNONN'LEDGEMENT: 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,Standar ,STATE td FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ti ��` DATE: `f ZL) <br /> PROPFRTI/Bus1NFSs OWNER❑ OPERATOR/MANAGER ❑ OTIIF.R Ai THORIZED AGENTO, <br /> lfAPPLICAAV is nol the BILLl.%'C;PARTY.proof of authorization to sign is required Tirl <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 samC6.!Ileit is <br /> Inv provided to me or y representative. !!'''�� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: r/? E® <br /> 08 <br /> ��4 0 <br /> WM CO ,9 <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: 4Z 151J�z <br /> ASSIGNED TO: ,? , EMPLOYEE#: el DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��, P I E: ( <br /> Fee Amount: Amount Pai > Payment Date77 <br /> Payment Type Invoice# Check# , / 3SS� Recei ed By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> s- <br />