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IL <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY 1D# SERVICE REQUEST# <br /> Grocery Store S ;~i <br /> OWNER 1 OPERATOR <br /> Todd POII'lel' CHECK if BILLING ADDRESS <br /> FACILITY NAME WinCo Foods,LLC <br /> SITE ADDRESS 2850Pavilion Parkway Tracy 95304 <br /> Street Number m,re . Street Name city Zip 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 ) 377-0110 212-280-180-000 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Ryan Barnett CHECK if 13ILLING ADDRESS <br /> BUSINESS NAME Bhilts Architecture PHONE# Exr. <br /> ( 208 ) 258-6155 <br /> HOME or MAILING ADDRESS 3156 South Bown Way FAx# <br /> ( 1 <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 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: IV, DATE: 12/04/2020 <br /> PROPERTY/BUSINESS OSVNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORtzEU AGENT[A Architect <br /> If APPLICANT is riot the BILLING PARTY,proof of authorization to sigh is required Ti1te <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: <br /> COMMENTS: ] f <br /> ACCEPTED BY: Ccs�� ✓� � S� � EMPLOYEE=#: DATE: 12 <br /> ASSIGNED TO: LVA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE:CODE: y P/E: <br /> Fee Amount: �. �—� Amount Paid Lf Payment Date <br /> Payment Type �fe� Invoice# Check# • ZZ � Received By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 _ <br />