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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail 3 S�QOC6� <br /> OWNER/OPERATOR <br /> Target Corp CHECK If BILLING ADDRESS <br /> FT152TFfvlanteca, CA <br /> SDDRESS <br /> Spreckels Avenue Manteca 95336 <br /> Street Numtrer Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 50 South 10th Street <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Minneapolis MN 55403 <br /> PHONE#1T' APN# LAND USE APPLICATION# <br /> ( 612) 761-6788 221-200-270-000 <br /> PHONE## BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tomas Kovalcik CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> Kimle -Horn and Associates Inc. 925 965-0594 <br /> HOME or MAILING ADDRESS FAX# <br /> 4637 Chabot Drive, Suite 300 ( ) <br /> Ci Pleasanton tTKE 64588 <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 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: T /��' DATE: 03/23/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Permit Expeditor <br /> I,fAPPLICANT is not the B/LLING 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 environinentaUsite 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 /> G A <br /> TYPE OF SERVICE REQUESTED: ` - ,- . l � OIL V <br /> COMMENTS: T <br /> Ila ns r� - i�✓t'V� iygR c�/VCU <br /> �YYI�C� . {�4vuCP.LbC�b�sWlfyy_ do <br /> 4^ n, C6`M HgN������0�2/ <br /> ACCEPTED BY: ( J EMPLOYEE M D' .T 6 <br /> ASSIGNED TO: EMPLOYEE#: DATE:3 _l <br /> Date Service Completed (if a eady completed): SERVICE CODE: Z� P I E:if �r <br /> Fee Amount: s — Amount P � Payment Date 3 3-6,121t0 <br /> Payment Typ Invoice# Check# c/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />