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QLons <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocery Store ?� �-7 <br /> OWNER/OPERATOR <br /> Smart & Final CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Smart& Final#393 <br /> SITE ADDRESS 744 W Hammer Lane Stockton 95207 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 600 Citadel Drive <br /> Street Numher Street Name <br /> CITY Commerce STATE CA ZIP 90040 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (323 ) 869-7500 8102016 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Amber Charles CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME MCG Architecture PHONE# EXT. <br /> 949 553-1117 <br /> HOME Or MAILING ADDRESS 111 Pacifica, Suite 280 FAX# <br /> CITY Irvine STATE CA ZIP 92618 <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 DEPAR'rMENT 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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPFR'ry/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT®_ Project Manager <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 ENVIRONMEN'rAL HEALTH DEPARTMENT as soon as it is available and at thes r� e it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Plan Checklle <br /> COMMENTS: <br /> D�cyla r 1 e s C m c, c�r ch i+e c�v 1'� . ►'� y FN�R Q411, ?418 <br /> ° .,e c K C I<dc C -{rccC7F 4 r 1 ��TNo AM FNr�,y�H�Y <br /> Vc <br /> `j< dui Y-06 K d cons-�r u�-(�o ►�1 - ►�'' <br /> RT,yFNT <br /> ACCEPTED BY: EMPLOYEE M � DATE: <br /> ASSIGNED TO: EMPLOYEE M 3� DATE: <br /> Date Service Completed (if already ompleted): SERVICE CODE: P/ : <br /> Fee Amount: Amount Pai �L�� Qv Payment Date /X I� ?- <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />