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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> - ' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery <br /> if'T[UUa ��� �ao7 �17c <br /> OWNER/OPERATOR <br /> Safeway, Inc, CHECK IfBILLINGADI)RESS❑ <br /> FACILITY NAME Safeway #2600 <br /> SITE ADDRESS 1801 IN lith Street Tracy 95376 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LANA USE APPLICATION# <br /> (209 ) 630-2950 232-170-24 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Debi Plaisance ( DebiPQC-p.com <br /> CHECK if BILLING ADDRESS <br /> BUSINESSNAME Ctlhaci & Peterson Architects PHONE# ExT. <br /> 407 643-2347 <br /> HOME or MAILING ADDRESS 1925 Prospect Ave. FAx# <br /> p 1407 ) 661-9101 <br /> CITY Orlando STATE FL ZIP 32814 <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 HEAL,THi 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 t formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FE aws. II <br /> APPLICANT'S SIGNATURE: DATE: �I�✓4 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGEN <br /> IfAPPLICANT is not the BILLING PARTY.Proof Of authorization to sign is reQuir Ti <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: Cir ECEIVED <br /> COMMENTS: SEP 15 2016 <br /> SAN JOAQUIN COUNTY <br /> EALTH D PAR <br /> HEMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE:lb�21 <br /> -1✓r. I <br /> Date Service Completed (If already Completed): SERVICE CODE: P IE: (� <br /> Fee Amount: GYM Amount Paid -& 0 Payment Date Ct r S V <br /> Payment Type C L Invoice# Check# •3 CIE Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />