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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TjpedfiltliasarPsu ate FACILITY ID# SERVICE REQUEST# <br /> RETAIL GROCERY 11 1 i � ' l7 C� �v�l�''Z <br /> Olt/OFBuffIR SAVE MART SUPERMARKETS, LLC 'r�.11 <br /> CHECK n BILLING ADDRESS W <br /> FAtdtmMilm SAVE MART#386 <br /> SDEAIa1M 1172 NORTH MAIN MANTECA 95336 <br /> Stmt Number ctlon St.1 NIrn. City Zip Coae <br /> #{(SEOfrAI�'.A� (it Different from Site Address) <br /> PO BOX 4278 <br /> Sine[Number et Nemo <br /> CITY MODESTO STATE CA ZIP 95352 <br /> AOKI" En 5339 APN# LAND USE APPLICATION It <br /> 1 209 ) 574-6299 <br /> PWO12 464-9431 En. BOS DISTRICT LOCATION CODE <br /> (209 ) 1 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> � <br /> � - ✓LG4�� �J'fr 13 <br /> ,[ CHECK If BILLING ADDRESS <br /> BusmomNAPE. 0,t- <br /> , PHONE# <) / LIZ <br /> � 33 <br /> FtD�orYAnimA FAX# l U <br /> 1 1 <br /> Cm STATE Zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andor project specific ENVIRONMENTAL HEAL'Ili DEPARTMENT 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance L odes,Standards.S I NTE and FI-DI RAL laws. <br /> APPLICANT'S SIGNATIJRS: �Q DATE../- 1/9 1Z3 <br /> PROPERTI IBI SI\ESS 011 Nr.R❑ OPERATOR/NIANACER ❑ OTIIER.LUTRORIZED AGENT LI_TDMplIArtce etadinAteY <br /> 1f IPP!i, r.,isnoithel3rtt L+'c PART) proofofauthorizariDNmsignisregnired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 11 is available and at thes�y mle It is <br /> provided to me or my representative. Y <br /> TYPE OF SERVICE REQUESTED: F r <br /> COMMENTS: O <br /> � 2t o1 C7Gt�l2e ✓S <br /> (/ SqN <br /> y �T'QY/�ZVQ <br /> C <br /> gON3 <br /> /V?- <br /> ACCEPTED <br /> ACCEPTED BY: Gt EMPLOYEE#: -{- DATE: i I ((^ I 1?, <br /> ASSIGNED TO: - EMPLOYEE#: 'J �L DATE: <br /> SL 1 <br /> Date Service Completed (it already completed): SERVICE CODE: t, �, 1 PIE: D -2— <br /> Fee <br /> LFee Amount: S-6,00 Amount Paid / DrJ Payment Date 3 <br /> Payment Type (1k Invoice# Check# Received By: <br /> EHD i I SR FORM(Golden Rod) <br /> REVISED 11)17/2003 <br />