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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEEREQUESfT�# <br /> Retail store O sP00p(KI1; <br /> OWNER/OPERATOR Target g CHECK If BILLING ADDRESS <br /> FACILITY NAME Target T853 <br /> SITEADDRESS 2355 W. Kettleman Lane Lodi 95242 <br /> m <br /> Street Nuber Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1000 Nicolett Mall <br /> Street Number Street Name <br /> CITY Minneapolis STATE MN Zip 55403 <br /> PHONE#1 EM APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/<CERVICE REQUESTOR <br /> REQUESTOR Samantha Olendorff CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Permit Place PHONE# 415-663-2112E"'' <br /> HOME or MAILING ADDRESS 13400 Riverside Dr. , Ste 202 FA%# <br /> CITY Sherman Oaks STATE CA ZIP 91423 <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: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER ADTHORizFDAGENT L't Permit Expeditor <br /> If APPLICANT is not the BILLING PARTY 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tl7e same time it is <br /> provided to me or my representative. q bx'�CyAkww <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: uAt <br /> cr <br /> FA $ <br /> � /UN <br /> irH�oq" oHos' E�Z� <br /> ACCEPTED BY: EMPLOYEE#: f .7 t DATE: <br /> ASSIGNEDTO: EMPLOYEE#: !' DATE: <br /> Date Service Com eted (if already completed): SERVICE CODE: 131 <br /> E: <br /> Fee Amount: Amount Pai (��j� Payment Date <br /> Payment Type Invoice# (,ems,, Check# 133 g �G S Received By: <br /> EHD 4&02-025 "�4 &p3%7 ( &-9 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 VVV <br />