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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T"RETAI�OCER� FACILITY ID# SERVICE REQUEST# <br /> LL C� <br /> 01IIee110PB ATM SAVE MART SUPERMARKETS, LLC <br /> CHECK K BI NG ADOr1ESS <br /> FemmirK E. SAVE MART#94 <br /> StTEADGMS 15240 S HARLAN RD LATHROP 95330 <br /> Stnet Number nC Ian NM <br /> Cit Code <br /> II EwlrAawGAt�(It DlNerenl from Sue Address) <br /> PO BOX 4278 <br /> SVeet Nnmber rest Name <br /> CITY MODESTO STATE CA ZIP 95352 <br /> Pith E.T.5339 APN# LAND USE APPLICATION# <br /> ( 209 ) 574-6299 <br /> RoEQ 858-4798 Ext BOS DISTRICT LOCATION COPE <br /> (209 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESiDR /r✓/ L�- LLL.L V✓LS/y✓/FA <br /> C O l / CHECK((BILLING ADORE55� <br /> BNArE Pxe. 4 .LY /tech CG' r�LtrGC�, Yr2wj <br /> HDE c r d1AamsG ADDRESS FAx# <br /> 1 1 <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 HEALT11 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 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,STATi and FEDERAI.laws. <br /> APPLICAM'SSICKATUU: f p DATE- 11923 <br /> PROPERTIi BUSINESS OWNER❑ OPERATOR I MANAGER E3 OTIIER LIITHORMED IGEYT O�mmQllwr� [LtDYL�IAaL ✓ <br /> Jf APPLICANT is not rhe/JlLI/NO PART) proof of uurdorizalion to sign is required rifle <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 HEALTH DEPARTMENT as soon as it is available and at he same time it is <br /> provided to me or my representative. �•7 <br /> TYPE OF SERVICE REQUESTED: C HT <br /> COMMENTS: <br /> sk� ' JA <br /> S4 JV jo2 <br /> 02023 <br /> (9 � � <br /> hF <br /> �-Ll C7HRojv�N u/V V <br /> n rMF <br /> ACCEPTED BY: EMPLOYEE#: x -� a DATE: , �S <br /> ASSIGNED TO: l EMPLOYEE#: v DATE: <br /> Date Service Completed (It already completed): SERVICE CODE: U I PIE 6l)L <br /> Fee Amount: . Amount Paid kpN� Payment Date <br /> Payment Type (I Invoice# Check# 'FK-7D3Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> J <br />