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)' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST e(2-019 <br />Type of Business or Property <br />Retail/Discount Store <br />FACILITY ID # <br />11-31-1- <br />SERVICE REQUEST # <br />0 (D B-1- 8 CI cr <br />OWNER/OPERATOR <br />CHECK if <br />Dollar Tree Stores <br />g BILLING ADDRESS , <br />FAciLrry NAME <br />Dollar Tree <br />SITE ADDRESS 2530 <br />Street Number Direction <br />Nag lee Rd <br />Street Name <br />Tracy <br />City <br />95304 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />500 Street Number <br />Volvo Parkway <br />Street Name <br />CITY STATE ZIP <br />Chesapeake VA 23320 <br />PHONE #1 ExT. <br />( 757 ) 991-5323 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Alesia Davis <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( 310 ) 781-8250 <br />EXT. <br />9 <br />HOME or MAILING ADDRESS <br />1111 Sartori Ave <br />FAX # <br />( ) <br />CITY <br />Torrance <br />STATE <br />CA <br />ZIP 90501 <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 />APPLICANT'S SIGNATURE: 4 <br />DATE: 4.1.24 <br />PROPERTY / BUSINESS OWNER El OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT Agent for Architect <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 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: Nle,...A.) fa-CAC.1.1,2.---- \ IR.C, 'e <br /> <br />irii ivio C,e7fr <br />COMMENTS: <br />APR lin <br />v J 2024 8,441 <br /> JO &-Alv 4 QUi i'i llz.r. /RON N Coo <br />Fi ipplIA/V7:4 (N7 <br />771k7v s <br />ACCEPTED BY: at Vrt4 {P . C <br />EMPLOYEE #: DATE: Zi ....1 __)......q i <br />ASSIGNED TO: 1,...) ket <br /> Y-1 c <br />EMPLOYEE #: DATE: ,It —I —21 <br />Date Service Completed (if already completed): SERVICE CODE: ,..5-2... P / E: / <br />Fee Amount: ,/t<taa — Amount Pii L4.R2 , Oz) Payment Date 1473/221-- <br />Payment Type V I .6z,i__ Invoice # Check # j7 1 Og61/4537 Received By: <br />7. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003