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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �^ Z3- <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ $ERVI REQUEST <br /> OWNER/OPERATOR S�`JinJ <br /> CHECK If BILLING ADDRESS <br /> Compass Group USA,Inc.dba Canteen <br /> FACILITYanteen @ Costco#658 Mark #2 <br /> SITE A(:DDRESS S Schulte Ct. Tracy 95377 <br /> 25862 Street Number I Direction street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Yorkmont Rd. <br /> Attn: Licensing 2400 Street Number Street Name <br /> CITY Chalotte STATE NC Zip 28217 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 704 ) 328-5184 <br /> PHONEW ExT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 529-5350 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: P 4 A4-- DATE. 9-28-2020IF <br /> p <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT[3 Assistant Secretary <br /> I,fAPPLLCANTisnotthe B1LL/NGPARTY proof of authorization t0 sign i5 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 andpQ' ii11q�ame time it is <br /> provided to me or my representative. /PP <br /> M1, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: otp <br /> sAN 1104 <br /> 9 720 <br /> Addition of second micro mallet µ ti eNVOUN <br /> du-tLV HEAL TH p gR'Mellir <br /> ACCEPTED BY: EMPLOYEE#: ZI3 DATE: Z <br /> C1 ot <br /> ASSIGNED TO: /.. _ � EMPLOYEE t fgg d DATE: 6/ /" ZO <br /> Date Service Completed .((ii-f a�lreeady completed): SERVICE CODE:p 1 P I E: a Z <br /> Fee Amount: �� Amount Paid d Payment Date q 29 Zd <br /> Payment Type C+L Invoice# Check# G7 131 Received By: <br /> Q� � pn -- Jr <br /> EHD 48-02-025 N+ l.V `�� t�f'T' ./1 10 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �` �rpl.o rT t Oq rj <br />