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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT G <br />SERVICE REQUEST <br />Type of Business or Property <br />Market <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />^\/ SERVICE REQUEST # <br />(^/ <br />1' v0 6 v/ <br />OWNER/ OPERATOR Safeway, Inc (parent company Albertsons' Companies) CHECK if BILLING ADDRESS❑ <br />FACILITY NAMES eway Market <br />EXT. <br />526-6655 <br />SITEADDRESS -T —Mountain <br />Street Number <br />Dlrecllon <br />House Parkway <br />Street Name <br />768-4678 <br />Mountain House <br />city I <br />95391 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 250 <br />David Palmer, Albertsons' Street Number <br />Q4/ 0 <br />Hcy H�Faq <br />East Parkcenter Blvd. <br />Street Name <br />CITY Boise <br />STATE ID ZIP 83706 <br />PHONE#t ExT. <br />(208) 395-5424 <br />APN# <br />254-55-029 <br />LAND USE APPLICATION# <br />PHONE#P EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Kevin McCook <br />9�-o^Y\2 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />Shea Properties <br />lGtylS rYn. C�J <br /># <br />858 <br />EXT. <br />526-6655 <br />HOME Or MAILING ADDRESS 9191 Towne Centr Dr., Suite 400 <br />FA"# <br />( 858) <br />768-4678 <br />CITY San Diego <br />STATE CA <br />ZIP 92122 <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 f/rm. <br />I also certify that I have prepared this application <br />COUNTY Ordinance Codes, Standards, STATE +C <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNERM <br />IfAPPLICANT is not the <br />the wg& to be performed will be done in accordance with all SAN JOAQUIN <br />Z' <br />DATE: <br />1 ❑ OTHER AUTHORIZED AGENT ❑ <br />J 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 thsame time it is <br />provided to me or my representative. �q L� <br />TYPE OF SERVICE REQUESTED: iN CIA) Wz,.2v <br />9�-o^Y\2 <br />C <br />COMMENTS: <br />lGtylS rYn. C�J <br />n ✓.e� <br />FCZ <br />Jo <br />Q4/ 0 <br />Hcy H�Faq <br />F <br />RTb NT <br />ACCEPTED BY:/- <br />.II.--�,CS <br />EMPLOYEEM <br />DATE: <br />ASSIGNED TO: <br />L_ . L-•Xav s- <br />EMPLOYEE #: <br />DATE: i 2--/ <br />Date Service Completed (If already completed): <br />SERVICE CODE: SZ3 <br />P 1 E: �� D <br />Fee Amount: <br />—' <br />Amount Paid, <br />Payment Date <br />Payment Type <br />15rt <br />Invoice # <br />Check # 11-736 9 /s 7 <br />Received By: <br />EHDSED 11/1 ���� U I I SR FORM (Golden Rod) S <br />REVISED 11/17/2003 J <br />