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��'C)Cs <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nnSEERRVI``CC�E REQUEST# <br /> RETAILER <br /> OWNER/OPERATOR <br /> BURLINGTON COAT FACTORY OF TEXAS,INC. CHECK if BILLING ADDRESS <br /> FACILITY NAME BURLINGTON #1471 <br /> SITE ADDRESS 3150 <br /> NAGLEE TRACY 95304-7319 <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ATTN.:TAX DEPT. 1830 ROUTE 130 NORTH <br /> Street Number Street Name <br /> CITY BURLINGTON STATE NJ Zip 08016-0317 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (609 ) 387-7800 53145 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> BURLINGTON 609 387-7800 53145 <br /> HOME or MAILING ADDRESS FAx# <br /> SAME AS ABOVE OWNER ( ) <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 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> oAPPLICANT'S SIGNATURE: — DATE: 10/9/23 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Business Analyst 1 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at Rte time it is <br /> provided to me or my representative. I���/M <br /> TYPE OF SERVICE REQUESTED: IVO <br /> I VE <br /> COMMENTS: Y✓Vl�'/Y �l �7 c P41 le— OV � 4 2023 <br /> SAN <br /> JOA <br /> HEN RONMENTUNTy <br /> �FPARTMENT <br /> ACCEPTED BY: :� r. /�v EMPLOYEE#: DATE: 114, <br /> �3 <br /> ASSIGNED TO: ,.�Jl EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: I Z <br /> Fee Amount: Amount Paid /(02,Dt) Payment Date / 3 <br /> Payment Type �- Invoice# Check# I�1 G93Z� Received By: <br /> EHD 48-02-025 o n�. 1 9 3 z SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />