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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 Unocal#6981; <br /> RWQCB Case#390204, <br /> OWNER/OPERATOR 76PP#351515 <br /> Target Corporation CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> �farget <br /> SITE ADDRESS 95207 <br /> 4707Pacific Avenue Stockton <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) NA <br /> PO BOX 111 <br /> Street Number NA Street Name <br /> CITY STATE ZIP <br /> Minneapolis MN 55440 <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> ( 612) 761-6385 108-160-04 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 707 ) 843.6032 (Jennifer Granbor Arcadis U.S. Inc. Consultant <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Katherine BrandtQ <br /> CHECK If BILLING ADDRESS <br /> EXT, <br /> BUSINESS NAME Arcadis U.S., Inc. PHD7I07)843-6032 (Jennifer Granb(rg) <br /> HOME or MAILING AD E$g FAX# <br /> 10� mrth Ranch Road, Suite 329 ( ) <br /> CITY STATE ZIP <br /> San qfael CA 94903 <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 /> ' 04/03/17 <br /> APPLICANT'S SIGNATURE: _ A4 L t, ( t � DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Professional Geologist <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />