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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TRUCIambsQNapN1j FACILITY ID# C ERVIC7E REQUEST# <br /> RETAIL GROCERY f ht V(�Q 2� L jill <br /> SAVE MART SUPERMARKETS, LLC CHECK If BILLING ADDRESS <br /> E mmaw FOODMAXX 9490 <br /> S MAmiait; 1950 W 11TH ST TRACY 95376 <br /> Stmt Number I Dirl5tion SI,.I Name cily Zia Cod. <br /> H1 OF W1r•GAEnVM(If Different from Site Address) <br /> PO BOX 4278 <br /> Street Numbar St.,Nema <br /> Crry MODESTO STATE CA ZIP 95352 <br /> PAIIIIIIIE21 IDa 5339 APN# LAND USE APPLICATION# <br /> ( 209 ) 574-6299 <br /> PWCEEIQ 832-38fi7 En SOS DISTRICT LOCAmONCOOE <br /> (209 I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> /Y� LZ— � %CS CHECK If BILLING ADDRESS <br /> S Y �' <br /> Bt ssNAKE , u- G Otitee fJy i�ct<�o� PHONE - . 2c o t;-3 <br /> How or WAND ADDRESS Fuc# <br /> 1 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and or project specific ENViRONMLNTAI. HI ALTA Di PARTMLNThourly charges associated with this project <br /> or activity will be billed tome 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 SIN <br /> COUNTY Ordinance Codes,Standards, S IATF and FEDERAL laws. <br /> "PUCAIIlTeSSIG ATlulte:C t��� C7�- DATE: 1/9Iz3 <br /> 1\ <br /> PROPERTY l BUSINESS O :NER❑ OPERATOR/AIANICER 13 OTHER \UTIIDRI7.ED %CENT¢Jr COfrlf]I/AI� CCj}Ydl.fl <br /> 1fAPPUCI,VT iS nor rhe RILUNG PART),proajajauthorization to sign is required f TWe <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 a environme al sac assessmem <br /> information to the SAN JOAQUIN COUNi—y ENVIRONMENTAL HEALTTI DEPARTh1CNT as soon as it is available andata�jagt�time it is <br /> provided to me or my representative. r t g1 <br /> TYPE OF SERVICE REQUESTED: EO <br /> COMMENTS: 9 <br /> G �� C t C7Cc Yt Pit SGu y� SAN✓ O 2023 <br /> () L3 / NV AQL/l/V <br /> yEA TNS PQRrMENTy <br /> ACCEPTED BY: r EMPLOYEE#: - DATE: CJI I 0 Z j <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C) P I E: i (Q C) <br /> Fee Amount: / Amount Paid 1# A6.OD Payment Date .I <br /> Payment Type ' Invoice# Check It 1 FUD3 Received By: <br /> EHD 48-02025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��eI�3321 S <br />