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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TjpeofBmi■IsterPtMmhr FACILITY ID# SERVICE REQUEST# <br /> RETAIL GROCERYL1[ �;�� <br /> 0■et;i[10P8tA71!]R SAVE MART SUPERMARKETS, LLC <br /> CHECK If 81LUNG ADDRESS <br /> .P <br /> FilamlME FOODMAXX#447 <br /> SMA00*0 610 W KETTLEMAN LANE LODI 95240 <br /> St , I, Street Name City Zip Code <br /> IbKWIIALEGADDII33 (If Different from Site Address) <br /> PO BOX 4278 <br /> Street NumOer tree)Name <br /> CITY MODESTO STATE CA ZIP 95352 <br /> I"=*1 ExT 5339 APN N LAND USE APPLICATION N <br /> ( 209 ) 574-6299 <br /> PWK IfZ 334-6853 E" BOS DIsMCT LOCATION CODE <br /> J209 ) <br /> r CONTRACTOR/ SERVICE REQUESTOR <br /> 1 7��Cr-C�i4�GLL�/ E7'Y SGS CHECK if BILUNG ADDRESSO <br /> BUISMIlEss NAME 7 - PHONE N E". <br /> 4o-e / tc'" G�t21� �a - <br /> -33, <br /> Ht]R�or Mm-m ADDRESS FAx# <br /> Cin' STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and or project specific ENV1RONNIFNTAL HLALIH Di PARTMt 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQL'1N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDCRAI,laws. <br /> APPWCANT-S UGNATUM- DATE: 1191.:R:3 <br /> PROPERTY/l usi%ESSOWNER 01 EIEILITOR i IGIGER TIIOR17.ED.iGENTEi C" I� CgDt'di n0-fVK <br /> IfAPPLICA\Tis not the BILLIAG PART).proof of authorization to sign 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 and or environmental,site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT)i Di:PARTNIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: C Cel <br /> I <br /> COMMENTS: D <br /> JAN?0 2012 <br /> HE N NAONMENTU Ty <br /> DEPARTME 7- <br /> ACCEPTED <br /> ACCEPTED BY: 7 } EMPLOYEE#: DATE: I C1 Z <br /> ASSIGNED TO: � _ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (G P 1 E: C) <br /> Fee Amount 66,8�> Amount Paid Payment Date �3 <br /> Payment Type / Invoice# Check# 703/ Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />