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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nnSE <br /> � RVI�'CILE, REQUEST# <br /> Retail Market 2� b4 �F�LID <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Car Coral Hollow LLC <br /> FACILITY NAME <br /> Safeway 2600 <br /> SITE ADDRESS 1n1 11 th Street Tracy 95376 <br /> 1301 Street Number Direction Street Name CI Zi 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 Ext. APN# LAND USE APPLICATION# <br /> ( 925 ) 580-7934 232-170-240-000 <br /> PHONE#2 Ext. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tait and Associates on behlaf of Safeway CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: �9 DATE: 8/16/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENTX 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 an-L—*�same time it is <br /> provided to me or my representative. 1w <br /> TYPE OF SERVICE REQUESTED: I VE p <br /> COMMENTS: <br /> saN./o G 181021 <br /> 4QUIN <br /> HEALTH 0,, M�N <br /> ACCEPTED BY: �f f,-q/ ,Oc, EMPLOYEE#: DATE: <br /> ASSIGNED TO: ,^ V--e EMPLOYEE#: DATE: •L l0 _—)�I <br /> Date Service Completed (if already completed): SERVICE CODE: Sy7J PIE: 1(00 ( <br /> Fee Amount: 4S(o - Amount Pa �-� Payment Date 2/ <br /> Payment Type / \ Invoice# Check# (�,- 4� Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />