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Type of Business or Property <br />Grocery <br />Facility Name Safeway #3124 <br />Site Address Main Street <br />Street Name <br />StateCityWalnut Creek CA <br />Land Use Application #Ext.APN # <br />219-350-46 <br />Location CodeBOS DistrictExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Kasey Peterson <br />Ext. <br />Business Name Cuhaci & Peterson Architects 865-919-4041 <br />Home or Mailing Address 1925 Prospect Ave.661-9101) <br />32814ZipCityOrlando <br />5/15/20APPLICANT’S SIGNATURE: <br />Permitting Coordinator <br />Title <br />Type of Service Requested: <br />Comments: <br />Accepted By:Employee #:Date: <br />Employee #:Date:Assigned to: <br />Amount Paid <br />Invoice # <br />*SR FORM (Golden Rod) <br />] <br />> <br />Phone #1 <br />( ) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Owner / Operator <br />Safeway Inc. <br />Phone #2 <br />( ) <br />Manteca <br />City <br />1371 <br />Street Number <br />95337 <br />Zip Code <br />s <br />Direction <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 />1 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 />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />Co 002-2-^1-0 2. <br />1187 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Check if Billing Address O <br />SERVICE REQUEST# <br />Check if Billing Address O <br />etwufc# <br />Date Service Completed (if already completed): <br />Fee Amoun <br />Payment Type <br />CT? <br />Service Code: <br />Payment Date <br />0^4 <br />Phone# <br />(___1 <br />Fax# <br />(407 <br />State fl <br />Petei-KM_____________________________ DATE: <br />Property / Business OwnerC Operator / Manager Other Authorized Agent EH <br />If APPLICANT is not the BILLING Party, proof of authorization to sign is required <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. Vz* <br />AFIT^NT <br />(>/%Q/^ <br />j PllWl <br />Received By: <br />Oakland Blvd, Suite 200 <br />______________________Street Name <br />Zip <br />94596