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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />TjpdR/IlttiltlstarRnlpef <br />FACILITY ID #VICE <br />REQUEST # <br />RETAIL GROCERY <br />FAX II <br />( ) <br />CITY STATE Zip <br />�I� <br />tD®eIGPOLO R SAVE MART SUPERMARKETS, LLC <br />DATE of /c' 2 2 <br />J <br />ASSIGNED TO: <br />CHECK I(BILUNG ADDRESS <br />Fillamltrlt>E SAVE MART #781 <br />EMPLOYEE#: <br />S"MilE s 875 <br />I <br />S TRACY BLVD <br />SERVICE CODE: v�v,' <br />TRACY <br />95376 <br />SIO♦t Numb♦r <br />DIMCIloo <br />IIIIIN HIM <br />Payment Date 23 <br />City <br />zip 4:04, <br />RCEorRILL=Amimia �, (If Different from Site Address) <br />PO BOX 427e <br />5Nro[ NumCer <br />51met Hem, <br />CITY MODESTO <br />STATE CA ZIP 95352 <br />PAM#1 ev.5339 <br />APN S' <br />LAND USE APPUCATION 1f <br />( 209 1 574-6299 <br />Ftm1IEQ 830-2840 En. <br />SOS DISTRICT <br />LOCATION CODE <br />( 209 ) <br />CONTRACTOR / SERVICE REQUESTOR <br />,/j •� f ��S CHECK if BILLING ADORE55 � <br />�YM�6 HAtI� <br />81/ / <br />Ge![ <br />PHIN1E -._ <br />Z 5 3 <br />HDIE or NAnm ADDRESS <br />FAX II <br />( ) <br />CITY STATE Zip <br />[i <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIi 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 />,AP M.jCANrS S K94A7URBt DATE: <br />19 / 2 3 <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTIIERAITIIORIZEDAGENTg CD11Lf1(IAr1Ce OODrV11rW0kV <br />1jdPPLICAAT is not the BILLING PART). proof ojaaNrorization 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 an&Or environmentallshe assessment <br />Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as II Is available and at the same time It is <br />provided to me or my representative. Pd VA <br />TYPE OF SERVICE REOuESTED: <br />COMMENTS: // <br />(0 <br />2 v23 <br />l C <br />SaN I04 7073 <br />HFA 7HDQP /Vr' OtJ"V <br />41617, <br />ACCEPTED BY: <br />EMPLOYEE #: -� U <br />DATE of /c' 2 2 <br />J <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already Completed): <br />SERVICE CODE: v�v,' <br />I <br />P 1 E: % U <br />Fee Amount. <br />/S . 0(::)Amount <br />Pald , Co <br />Payment Date 23 <br />Payment Type <br />(2� <br />Invoice # <br />Check # )97703/ <br />1 Received By:11M- <br />EHO 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />