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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 �(� 00-7c614 <br /> OWNER/OPERATOR <br /> Nicholas Speno(Trustee) CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Safeway#1769 <br /> SITE ADDRESS 2808 Country Club Blvd Stockton 95204 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1371 Oakland Blvd,Suite 200 <br /> Street Number Street Name <br /> CITY Walnut Creek STATE CA ZIP <br /> 94596 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 121-180-43 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( 0 03 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kasey Wybrant Kaseyw@c-p.com CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Cuhaci & Peterson Architects PHONE# ExT. <br /> 407 661-9100 2413 <br /> HOME or MAILING ADDRESS 1925 Prospect Ave. FAx# <br /> P (407 ) 661-9101 <br /> CITY Orlando STATE FL ZIP 32814 <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,STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BCSINESS OWNER❑ OPe.RATO /MAN :R ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 a'bthe same time it is <br /> provided to me or my representative. A,q <br /> TYPE OF SERVICE REQUESTED: O o c Y lq ' CFI NT <br /> COMMENTS: 2 <br /> tiMFCO�O�� <br /> ACCEPTED BY: EMPLOYEE#: DATE: / <br /> ASSIGNED TO: V7 L EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: ��Qq <br /> L Amount Paid 2 0� Payment Date // 7 <br /> Payment Type Invoice# Check# Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />