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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 2�Qqqc( <br /> OWNER/OPERATOR JJI JVf <br /> Safeway Nor. Cal Divison CHECK If BILLING ADDRESS Er <br /> FACILITY NAME Safeway #1769 Grocery Store <br /> SITE ADDRESS 2808 Country Club Blvd Stockton 95204 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Stoneridge Mall Road <br /> 5918 Street Number Street Name <br /> CITY Pleasanton STATE CA Zip 94588 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (341) - 777-5431 121-118-043 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TBD CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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: DATE: 7-5-2022 <br /> PROPERTY/BUSINESS OWNER13 OPERATOR/MANAGER ❑ OTHER AUTHORIZEOAGENT M Architect <br /> IfAPPL/CANT is not the BILLING PARTP 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 at the same time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: K41,1✓1 pr re OA-9cle <br /> COMMENTS: e 40(u.✓�f �U� 1 ' <br /> RO tSMJOAQUilf ilf CEALTHOUNrY <br /> mi�oOh Q a�b�t "M H DEQ Nr <br /> ACCEPTEDBY: �-Ge rfKCSC:ia EMPLOYEE#: DATE: �I-t —9�,'Lz <br /> ASSIGNED TO: '1-.,� EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready completed): SERVICE CODE: S2.3 PIE: <br /> Fee Amount: Amount Paid 4U�V� Payment Date <br /> Payment Type Invoice# leem. Ho —q(e Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />