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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tjpledd�tfasarPla�it[r!� FACILITY ID# SERVICEgT <br /> RETAIL GROCERY y��� �Q l (i�nU;�✓ 1� <br /> OMM3110P SAVE MART SUPERMARKETS, LLC <br /> CHECK If BILLING ADDRESS <br /> FarllsalrlMttiE SAVE MART#655 <br /> 530 W LODI AVE LODI 95240 <br /> Steel NumbJ—Pirveti.. I Streel Name City Zip Code <br /> HOMM W.11111GAMOREW (if Different from Site Address) <br /> PO BOX 4278 <br /> Street Number !reef Na • <br /> CITY MODESTO STATE CA Zip 95352 <br /> RtM#1 FXT.5339 APN# LAND USE APPLICATION# <br /> ( 209 ) 574-6299 <br /> PMMEAZ 339-7170 E" BOS DISTRICT LOCATION CODE <br /> (209 ) 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> MMMTM iJ ,l .� *�� ` p Jam!S CHECK if BILLING ADDRESS❑ <br /> B }� "�usatlNAMEas NAME PNoNE# EXT._ <br /> ! or IIlnawa 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 HEALTI-I DEPARTNIENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form- <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQI'IN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APAP<acArM S1GNA1< =-. - DATB: 1/0-2-3 <br /> PROPERTY I Ht SISESS OWNER❑ OPERATOR I NI%%AGER ❑ OTI•ER ACTItORIZED AGENT <br /> If 1 PPLIC WT is not the BILLIAG P IRT),proof ojarrthorization to sign is required Trac <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 ENVIRONNtENTAL HEALTI I DL PARTMI Ni as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: N <br /> COMMENTS: / c <br /> / N2 <br /> sgNjo 02023 <br /> NEq�rHDQ gEN0PA17�- <br /> RT <br /> ACCEPTED BY: Com` -- EMPLOYEE#: �J 71 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �, > <br /> c.� <br /> Fee Amount: i�4,U0 Amount Paid �5�. Payment Date <br /> Payment Type Invoice# Check# 'gg 7b3 Received By: <br /> EHD 48-02-025 SR FORM(Galden R:d) <br /> REVISED 11/17/2003 <br />