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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businessor Pilty FACILITY ID# SER�VIC�R ST# <br /> Existingstore <br /> OWNER/OPERATOR <br /> Dollar General CHECK if BILLING ADDRESSID <br /> FACILITY NAME Dollar General <br /> SITEADDRESS 1940 McHenry Ave Escalon 95320 - <br /> Street Number Direction I city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 100 Mission Ridge <br /> Street Number Street Name <br /> CITY Goodlettsville STATE TN ZIP 37072 <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> (615 1 855-4728 227-680-310-000 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Laile Giansetto-Architect <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> PSM Architects,Inc 510 655-1922 <br /> HOME or MAILING ADDRESS FAX# <br /> 2423 Edwards Street ( ) laile@psmarcHtects.com <br /> CITY Berkeley <br /> STATE CA ZIP 94702 <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 /> 1 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 FE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7/24/2020 <br /> PROPERTY/BUSINESS OWNER❑ OP�/MANAGER ❑ OTHER AUTHORIZED/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> ]jAPPL/CANT is not the BlLLtNG PAR7Y proof of authorization 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 environ ental/site assessment <br /> information to the SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anNil�Opfa�me time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Plan Check for minor remodel of existing retail store <br /> COMMENTS: <br /> O <br /> N q Njo DF AE!CoU,V <br /> RTjyFNT <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE M 6213 DATE: 7-28-20 <br /> ASSIGNED TO: Gehane Falmly EMPLOYEE#: 8788 DATE: 7-28-20 <br /> Date Service Completed (if already completed): IJ SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Paid TO to U� Payment Date 7 Zi7 <br /> Payment Type V�sa- Invoice# Check# //172-5-44 c9- Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />