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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery Store ZO S g J P0�9'q r7r <br /> OWNER I OPERATOR <br /> Todd POIOei CHECK If BILLING ADDRESS <br /> FACILITY NAME WinCo Foods,LLC <br /> SITE ADDRESS 2850 Pavilion Parkway Tracy 95304 <br /> Street Number I Direction Street Name city Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 650 N.Armstrong Place <br /> Street Number Street Name <br /> CITY Boise STATE Idaho ZIP 83704 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 208 1 377-0110 212-280-180-000 <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ryan Barnett CHECK If BILLING ADDRESS <br /> BUSINESS NAME Bhi]]S Architecture PHONE# Exr' <br /> 208 258-6155 <br /> HOME or MAILING ADDRESS 3156 South Hewn Way Fax# <br /> CITY Boise STATE ID ZIP 83706 <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 1 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: DATE: 12/04/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> 7fAPPL7CANT 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 and at the same time it is <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: E(QG'(ti(}YtIC� C�'c.�JvL'Lt`rT-e�-� <br /> COMMENTS: ('DL( b y Cc^e d'r� Ca <br /> ACCEPTED BY:' �-� C S�. EMPLOYEE#: DATE: (^I` <br /> ASSIGNED TO: L vA ' `cA � s-( EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Sy3 PIE: ( /o O/ <br /> Fee Amount: �"S(O Amount PaidL' S'b Payment Date I � Z� <br /> Payment Type v✓e� Invoice# 3 l{'L '� O Ch ck I 6 Z2 �� Received By: <br /> EHD 48-02-025 �t SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />