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SAN JOAQOUNTY ENVIRONMENTAL HEALTh_✓EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# Z SERVICE REQUEST# <br /> Retail Unocal#6981; D O Z3 ,� <br /> B Case#390201L_ 00 -7 <br /> OWNER/OPERATOR 76PP#351515 <br /> Target Corporation CHECK If BILLING ADDRESS❑ <br /> FACILITY NE <br /> �arget <br /> SITE ADDRESS 95207 <br /> 4707 Pacific Avenue Stockton <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) \A <br /> PO Box 111 <br /> Street Number NA Street Name <br /> CIN STATE ZIP <br /> Minneapolis MN 55440 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 612) 761-6385 108-160-04 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 707 )843.6032 ennifer Granbor Arcadis U.S. Inc. f Consultant <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Katherine Brandt CHECK if BILLING ADDRESS❑ <br /> PHONE EXT• <br /> BUSINESS NAME <br /> Arcadis U.S.,Inc. 70/ 843-6032 (Jennifer Granb(rg) <br /> HOME or MAILING AD E$$ FAX# <br /> 10 m1tII Ranch Road, Suite 329 ( ) <br /> CITY STATE Zip <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: 04/03/17 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Professional Geologist <br /> If APPLICANT is not the BILGING 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 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: 1 l� utFi1/ I ' <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: V DATE: <br /> ASSIGNED TO: EMPLOYEE#: I"� DATE: ' , <br /> Date Service Completed if already completed): SERVICE CODE: P I <br /> Fee Amount: Amount Paid Payment Da(e <br /> Payment Type Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />