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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tjptetf8�sarlaraprlt� FACILITY ID# gRVICE REQUEST# <br /> RETAIL GROCERY <br /> Opti OsISIUMDR SAVE MART SUPERMARKETS, LLC <br /> CHECK If BILLING ADDRESS <br /> FaamlYtlE SAVE MART#334 <br /> SWA=i 3215 PACIFIC AVE STOCKTON 95204 <br /> Street Numb.r I 01 ctlo r..t Nam. City ZloCod. <br /> IIMorI L4LMGADDRM (If Different from Site Address) <br /> PO BOX 4278 <br /> Stmt Number st.01 N.me <br /> CITY MODESTO STATE CA ZIP 95352 <br /> FIiiiiii�91 EXT 5339 APN# LAND Use APPLICATION Y <br /> ( 209 ) 574.6299 <br /> win464-9431 rs SOS DISTRICT LocAnoN CooE <br /> (209 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> CHECK H BILLING ADORESS❑ <br /> Eh NAIDE PHONE# <br /> Eti�f sz t-Gry/y c�l�ac— (hoT_ Ku7`D� o°' <br /> HtaE orNALmo ADDRIESS FAx# <br /> ( I <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and or project specific ENVIRONMENTAL HEACI71 DEPARTNIENT hourly charges associaled 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 JOAQVIN <br /> COUNTY Ordinance Coder,Standards,STA 1d FLDLRAL laws. <br /> A"UCA"S 81cNAnMfj DATE: 119123 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/YI%NAGER ❑ OTHER A UTIIORIZEDAGENT 0 cDn.CJItancP cvlxrdWz[r � <br /> IjdPPLICa,%r is not rhe RILLI,ca P.tRTI proof of authorization to sign is required ` Titre <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 HEALTII DEPARTMENT as soon as it is available and "k same time it is <br /> provided to me or my representative. I14 yc <br /> TYPE OF SERVICE REQUESTED: r� <br /> COMMENTS: <br /> SAN./ N 201073 <br /> �/0 M V7 (cc n CPQ cc,) 5 0. l2 YY GL.'� . C <� 1 �2 Ty p�p'V�����y <br /> ACCEPTEDBY: �t--�' L EMPLOYEE#: -z 77� -2 = DATE: d1110123 <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (It already completed): SERVICE CODE: PIE: <br /> Fee Amount: ��� Amount Pa ,U(� Payment Date Z <br /> Payment Type t1l Invoice# Check# 95 Receiv By: <br /> EHD 4802-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />