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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SEhR�V/ICE REQUEST# <br /> Retail Market *Z2� 0 SRo0�yogtp <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS 19 <br /> Car Coral Hollow LLC <br /> FACILITY NAME <br /> Safeway 2600 <br /> SITEADDRESS W 11 th Street Tracy 95376 <br /> 1601 Street Number I Dlrectlon Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 5918 Stoneridge Mall Rd.Pleasanton CA 94588 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 925 ) 580-7934 232-170-240-000 <br /> PHONE#I Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR% SERVICE REQUESTOR <br /> REQUESTOR Tail and Associates on behlaf of Safeway CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Eur. <br /> HOME or MAILING ADDRESS FA%# <br /> t ) <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: D!f�! DATE: 8/16/2021 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER OTHER AUTHORIZED AGENT JCY, Permit Coordinator <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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andplr tJle same time it is <br /> provided to me or my representative. rich�'M1, <br /> TYPE OF SERVICE REQUESTED: ,I/� '• �D <br /> COMMENTS: UG '8 1011 <br /> SAN JDA <br /> ENVIR NI coUNTy <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C... f f-,1..(' V EMPLOYEE#: DATE: <br /> ASSIGNEDTO: � �� EMPLOYEE#: DATE: aigy,l -ter <br /> Date Service Completed (if already completed): SERVICE CODE: S1-3 PIE: p I <br /> Fee Amount: 45(v — Amount Pal _S(O dD Payment Date 2f <br /> Payment Type / ` Invoice# Check# �� ! Receive By: <br /> EHD 025 /'y(I O p SR FORM(Golden Rod) <br /> REVISEDSED 11/1712003 <br />