Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery Store -2,2 Z {Spt��n���`l� <br /> OWNER/OPERATOR Jr{,(�' V <br /> Safeway Nor. Cal Divison CHECK if BILLING ADDRESS <br /> FACILITY NAME Safeway 43124 Grocery Store <br /> SITE ADDRESS <br /> 1187 S . Main Street Manteca 95337 <br /> Street Number I Direction I Street Name city ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Stoneridge Mall Road <br /> 5 918 Street Number Street Name <br /> CITY Pleasanton STATE CA ZIP 94588 <br /> PHONE#1 Ex-T. APN# LAND USE APPLICATION# <br /> (341) - 777-5431 21935046 <br /> —7 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 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 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: DATE: 7-5-2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> if APPLICANT is not the BILLING 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. Q <br /> IVA <br /> TYPE OF SERVICE REQUESTED: yLw tyvt.7t,(Zyvr <br /> COMMENTS: e—l eL��" �yiG p L0..a5 <br /> l <br /> MFH q��Y <br /> 'gRT'yFH <br /> ACCEPTED BY: �t�u�S EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: —7_�s- �2Z <br /> Date Service Completed if already completed): SERVICE CODE: 512-3 PIE: �U <br /> Fee Amount: Amount Paid Payment Date 'I' 22 <br /> Payment Type Invoice# 1 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />