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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery Store Z'? q ?j sRooSr9IN <br /> IN72 <br /> OWNER/OPERATOR <br /> Safeway Nor. Cal Divisor CHECK If BILLING ADDRESS <br /> FACILITY NAME Safeway #2707 Grocery Store <br /> SITE ADDRESS 6445 Pacific Ave Stockton 95207 <br /> Street Number I Direction I Street Name city zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Stoneridge Mall Road <br /> 5918 Street Number Street Name <br /> CITY Pleasanton STATE CA Zip 94588 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (341) - 777-5431 121-118-043 <br /> PHONE K Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TBD CHECKH BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ear' <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 pr erty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirorun <br /> it <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anlE��l it is <br /> provided to me or my representative. e VE <br /> TYPE OF SERVICE REQUESTED: Vvt.IVlov/ re MVA e-( JUL 114,2 <br /> COMMENTS: _( if - f _ dG r�IQ�s UOAQUINCOU + <br /> G GTIb Y� N l H4�DE�MEL <br /> ACCEPTED BY: � EMPLOYEE M DATE: -7 Si, Z2 <br /> ASSIGNED TO: mjLr EMPLOYEE III: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52:75 PI E:: ( Q� <br /> Fee Amount: 1409, —� Amount Paid /. Payment Date -411112-2— <br /> Payment Type Invoice# CMecirg Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />