Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TjpedIlluitstlsQFlllpeEj FACILITY ID# S RVICE REQUEST# <br /> RETAIL GROCERY 1 9 C'� LC;q+ I` —� <br /> 00tll 10PER"M SAVE MART SUPERMARKETS, LLC <br /> CHECK If BILLING ADDRESSM <br /> FittamRtlE SAVE MART#39 ` <br /> SMEAmtM 4725 OVAL LAKES DR STOCKTON 95207 <br /> Slreel N.mb. 51.v Name City ZIP Coda <br /> HMCW KUJNGAMORESS (If Differentfrom Slte Addrass) <br /> PO BOX 4278 <br /> Street Stn.t Nam. <br /> CITY MODESTO STATE CA ZIP 95352 <br /> AIIIIIIIIIIIEW x.5339 APN# LAND USE APPLICATION# <br /> ( 209 1 574 6299 <br /> HNIIIIIIIENZ 952.0525 En BOS DISTRICT LOCATION CODE <br /> (209 1 <br /> //,, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUIEMM ("Y7,-/,Y-, Z ✓ I-z'� /y/� ✓{SCS LL CHECK If BILUNG ADDRESS❑ <br /> BusErts NAS S��cF[' � Irl r�r'vc r-!/aY PHONE% �-� � � /fXT.J'3 <br /> HueorlillAa lOA,DDREn Fuc# <br /> ( 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned properly or business owner, operator or authorized agent or same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII DEPARTNII.NT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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, SLATE and FEDERAL laws. <br /> APPLICANTS SIGNATUREC DATE.— 1112 3 � <br /> PROPS RT\'J D I sl N Ess Ott'NE N❑ OPER\TOR/AIANAGER ❑ OTHER AuTIIORIZED.%CE.NT&rcoeIpll,&V - (iwgy <br /> nr <br /> If I PPI.ICdA7 is Not rile BILLING Pd RTI proof of authorization to sign is required —s Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at file <br /> above site address, hereby authorize the release of any and all results, geotechnical data and or environmental.site(a�ss_essment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and al the Salri[EI� t is <br /> provided to me or my representative. R �FNT <br /> TYPE OF SERVICE REQUESTED: O <br /> COMMENTS: <br /> el u0 ktt-✓sGL. saNilqlv�o ?� ?p3 <br /> Neq�TH��agR Me TY <br /> T <br /> ACCEPTED BY: �� <br /> - EMPLOYEE#: � �. -� '� DATE; I ( � <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: C)C P I E: r 0 '2- <br /> Fee Amount 5(DIA'� Amount Pald /S- 0D Payment Date <br /> Payment Type Invoice# Check# I�j g7O3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 71/17/2003 <br />