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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TjFdet�itsurllapu� FACILITY ID# SERVICE REQUEST# <br /> r <br /> RETAIL GROCERY I" A 00 (w UOO JU 2Jq <br /> SAVE MART SUPERMARKETS, LLC CHECK IfBILuNaADDRESS <br /> ffcummm SAVE MART#100 <br /> 1453 S GOODVVIN DR RIPON 95366 <br /> Stmt Number I n �N,,bw <br /> CII Cate <br /> llmwll a=AH S of Different from Site Address) <br /> PO BOX 4278 <br /> tmet , <br /> CITY MODESTO STATE CA ZIP 95352 <br /> 1'1Q1h r 5339 APN# LAND USE APPLICATION# <br /> ( 209 1 574.6299 <br /> 599-3355 ENT BCS DISTRICT LOCATION CODE <br /> (209 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUIESMIlt <br /> — fit Yl S CHECK If BILLING ACIOR93S❑ <br /> 7taNAME eek /`Z«✓ �m auee_ CerO/✓ter-1� p"Ro <br /> howornRousaaftaftess FAX# <br /> Cm 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 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 perfo ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE FEDERAL laws. <br /> ,A"1.ICAN1S" 8GNATUM it• rt DATrE <br /> . <br /> f/9 12-3 ,r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AI.\9\GER ❑ OTIIER,\UTIIORIZEDAGENTYJry�II*,nc,*- txloYOflnR}ta' <br /> IfaPPUGINT is not the BILLING PART) proof grauthorizadon losign is required Title <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 andror environmentalrsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Jr, <br /> COMMENTS: 1 -FY <br /> HE N �3 <br /> L',',,4 PpENyq <br /> I. <br /> ACCEPTED BY: - - F-7 EMPLOYEE#: `J �2`� DATE: i ( 0 23 FNT <br /> ASSIGNED TO: EMPLOYEE DATE'. i tTy 2.3 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 6 f� '2— <br /> Fee <br /> LFee Amount: la, Amount Paid �' Payment Date <br /> Z <br /> Payment Type invoice# 1 Check# I�7 7DReceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />