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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE R+EQlJST # <br />Walmart Store #2025 Tracy, CA <br />PHONE# ExT. <br />ZZ % <br />qRF� <br />POI(I�/'%j!1 7 <br />OWNER / OPERATOR <br />MFN <br />FAX # <br />Walmart Stores, Inc. <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SW <br />Merriam <br />Walmart Store #2025 Trac , CA <br />Date Service Completed (if already completed): <br />SITE ADDRESS 3010 <br />W <br />E: 7 ' <br />Grant Line Road <br />Amount Pal <br />Tracy <br />95304 <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />Check # a� �_jj 2,' <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />3010 <br />Grant Line Road <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Tracy <br />CA 95304 <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 836-5786 <br />238-600-10 <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />--71 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RELIUESTOR <br />Teresa Jones <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />tic��Nl.�R�Q41 <br />Tti�F Ob�N <br />PHONE# ExT. <br />BRR Architecture, Inc. <br />qRF� <br />913 262-9095 <br />HOME or MAILING ADDRESS <br />MFN <br />FAX # <br />Antioch Plaza Suite 300 <br />EMPLOYEE #: <br />( ) <br />C6�700 <br />SW <br />Merriam <br />66204 <br />BILLING ACKNOWLEDGEMENT: I, the w <br />acknowledge that all site and/or projecf specific <br />or activity will be billed to me or my bI siness as' <br />A. I . <br />I also certify that I have pr( <br />COUNTY Ordinance Codes, <br />APPLICANT'S SIGNATURE' <br />property or business owner, operator or authorized agent of same, <br />iENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />on this form. <br />work to be performed will be done in accordance with all SAN JOAQUIN <br />DATE: 12/19/18 <br />PROPERTY / BUSINESS OWNER OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Coordinator <br />If APPLICANT is not the BILLING RTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFO TION: 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„t��ipme it is <br />provided to me or my representative. '0,^I %o _ <br />TYPE OF SERVICE REQUESTED: �� (� � ��' ('V(� v -n <br />COMMENTS: <br />0 <br />" <br />tic��Nl.�R�Q41 <br />Tti�F Ob�N <br />qRF� <br />MFN <br />ACCEPTED BY: a vt (_ <br />EMPLOYEE #: <br />DATE: L� <br />g <br />ASSIGNED TO: l (� G L <br />EMPLOYEE #: <br />DATE: 2, <br />Date Service Completed (if already completed): <br />SERVICE CODE: �-1 <br />E: 7 ' <br />Fee Amount: M ,, : <br />Amount Pal <br />-OD <br />Payment Date <br />26 1 �- <br />Payment Type <br />Invoice # <br />Check # a� �_jj 2,' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />