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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Market �2 �9- �R0?y p <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Car Coral Hollow LLC <br /> FACILITY NAME <br /> Safeway 2600 <br /> SITE ADDRESS VV 11thStreet Tracy 95376 <br /> 1801 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 5918 Stoneridge Mall Rd.Pleasanton CA 94588 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 925 ) 580-7934 232-170-240-000 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tait and Associates on behlaf of Safeway CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <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 /> APPLICANT'S SIGNATURE: �6� DATE: 8/16/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Permit Coordinator <br /> IfAPPGICANT 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ant Iq same time it is <br /> provided to me or my representative. Ir/y YME <br /> ON <br /> TYPE OF SERVICE REQUESTED: I VE p <br /> COMMENTS: UG 18 2021 <br /> SgJOA <br /> ENViR QUINv OE COU <br /> NTV <br /> HEA LTH pE ARTM NT <br /> ACCEPTED BY: 'C c EMPLOYEE#: DATE: <br /> i Co 21 <br /> ASSIGNED TO: V�Gi EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: "S-1-3P/E: <br /> Fee Amount: 45(� - Amount Pai �V� DD Payment Date 2� <br /> j Payment Type Invoice# Check# �_ <.{.1 Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />