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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tipa(9rsirrsarPmpat7l FACILITY ID# ER(ICE REQUEST# <br /> RETAIL GROCERY rA � Qi Z( D k, / � 2 <br /> 0iiiiiiiiIiit10PBUtaR SAVE MART SUPERMARKETS, LLC <br /> CHECK If BILLING ADDRESS <br /> FmorrN E SAVE MART#91 <br /> SmIl7506 PACIFIC AVE STOCKTON 95207 <br /> Street Number= Stmet Name city ZIP Cooe <br /> P EMOkL CAi(If Different from Site Address) <br /> PO BOX 4278 <br /> Sueel Number st..t Name <br /> CITY MODESTO STATE CA ZIP 95352 <br /> F? ri E".5339 APN# LAND DSE APPLICATION# <br /> ( 209 1 574-6299 <br /> FINW R 952-0525 En. BOS DISTRICT LocnnoN coDE <br /> (209 I <br /> / <br /> CONTRACTOR/ `SERVICE REQUESTOR <br /> � CHECK If BILLING ADDRESS[] <br /> imFssNMW szcY 1L�2-t L LCTr12 " Lciltl(i" t7bY ntt/a f PLRE1 :-4 -�'1`/Y EXT J <br /> i- orWIiLmaAOD�S FAx# <br /> ( ) <br /> CITY STATE ZIP <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 DEPARTML NT 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 JOAQI7N <br /> COUNTY Ordinance Cortes„Standards,STATE and FEDERAL laws. <br /> AppucAN7'sSIGNATURE: ��_i� / DATE-/ 1 3 9(2 r <br /> P ROPE RT I'I Rust N ESS OM NE M❑ OPERATOR/INI%N:1GER ❑ 0 rIIER A"OORIZED AGENTIJ C� /1 <br /> lt [LmyyC6%4M' <br /> IJ.-IPPLICANT is not lire IIILLLYG PART) proof of autliorization to sign ib required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, [, 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 HI At TH DI PARTMtNT as soon as it is available and at the same time it is <br /> provided to me or my representative. PA I <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: CO <br /> G'�Ctea Ol�GL�l2L YS�t-C <br /> JAN <br /> l/ <br /> s 202023 <br /> ?023 <br /> HFA�TH�P�RM7-4 T <br /> ACCEPTED BY: EMPLOYEE III: `.� `� DATE: <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: <br /> Date Service Compr�rleted (If already completed): SERVICE CODE: �- PIE: C) L <br /> i <br /> Fee Amount: DD Amount Palcl �S a� Payment Date <br /> Payment Type Invoice# Check 0 rgg7 r Received By- <br /> EHD 48.02-025 SR FORM(Golden Red) <br /> REVISED 1 1/1 71200 3 <br />