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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail - WalMartrN <br /> OWNER / OPERATOR <br /> WalMart Stores Inc . CHECK If BILLING ADDRESS <br /> FACILITY NAME WalMart # 1554 <br /> SITE ADDRESS 3223 E Hammer Lane Stockton 95212 <br /> Street Number Direction Street Name city ZID Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) 2608 SE J Street <br /> Street Number Street Name <br /> CITY Bentonville STATE zip <br /> 72716 <br /> PHONE #1 EXT• APN # LAAND USE APPLICATION # <br /> ( 479 ) 2734000 126 - 180 - 06 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) O0 2- c <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Contractor TBD CHECK if BILLING ADDRESS ❑ <br /> BUSINESS NAME PHONE # EXT . <br /> HOME or MAILING ADDRESS FAX # <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 ETJVIRONME VIFAL 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 : cfevla 4w, DATE : 8/25 /2020 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 115 Permit Coordinator <br /> IfAPPLICANT is not the BILLING PARTY <br /> , proof of attthol•ilation 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 /> A IN COUN TY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and s me time it i <br /> information to the SAN JOU C s <br /> provided to me or my representative . <br /> 1�0 t/ V9111 <br /> TYPE OF SERVICE REQUESTED : 1 � � <br /> COMMENTS : S O , 202`0 <br /> I 1 AN JCA <br /> i NEgLTH pq�NTO lNTy <br /> RT/L7eNT <br /> ACCEPTED BY : , rAn Y ,� EMPLOYEE M DATE : <br /> ASSIGNED TO : , v �w " EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : i� PIE : <br /> Fee Amount : Amount Paid U2�sPayment Date2D <br /> Payment Type Invoice # Check # 13� 37 87ESl] Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />