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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �yy ��yy SERVICE REQUEST <br /> TReeta�illDSales—parts, crafts, Elm— <br /> OWNER <br /> FACILITY ID# SERVICEREQUEST# <br /> su lies/OPERATOR Hobby Lobby Stores, Inc CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Hobby Lobby Stores, Inc #947 <br /> SITE ADDRESS 3100 Naglee Road Tracy 95304 <br /> Street Number I Direction I Street Name city ZipCode <br /> HOME OrMAILING ADDRESS (if Different TAXI�DEPTs) 7707 SW 44th St <br /> Street Number Stme Name <br /> CITY Oklahoma City STATE OK Zip 73179 <br /> PHONE#1 EX. APN# LAND USE APPLICATION# <br /> (405) 745-5394 <br /> PHONER Ext. BOS DISTRICT LOCATION CODE <br /> (405 ) 745-1100 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Stephanie Franklin CHECK if BILLING ADDRESS® <br /> BUSINESSNAME Hobby Lobby Stores, Inc PHONE# EXT, <br /> (405) 745-5394 <br /> HOME or MAILING ADDRESS FAX# <br /> ATTN: TAX DEPT 7707 SW 44th St (405 ) 745-7300 <br /> CITY Oklahoma City STATE OK Zip 73179 <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,Standargs.STATE and <br /> _FEDERAL laws.laws. <br /> , ,, <br /> APPLICANT'S SIGNATURE: 6 o t t/ DATE: 08/31/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Tax Clerk <br /> /fAPPmcANT 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. nA. <br /> c <br /> TYPE OF SERVICE REQUESTED: , <br /> COMMENTS: vt�D <br /> SEP 08 7021 <br /> SAfy jpgQU1 <br /> HEgLTH pEpgR Me N <br /> �^ p <br /> Nr <br /> ACCEPTED \ EMPLOYEEM DATE: R 0 2I <br /> ASSIGNED TO: �Ad"Afl CA,JJJ EMPLOYEEqsyg DATE: I V <br /> Date Service Completed (if already completed): SERVICE CODE: 00 P/E: I W 0;�' <br /> Fee Amount: Amount Pa �S�, Payment Date -1-21 <br /> Payment Type Invoice# Check# 1-7 S(o Received By: <br /> EHD 48-02-025 nSR FORM(Golden Rod) <br /> REVISED 11/17/2003 gliq 45 <br />