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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAST FOOD FA0002340 5(2oo (,56V <br /> OwNeRIOPERATOR QUIKSERVE ENTERPRISES INC CHECK if BILLINGADDR9SJ19 <br /> F=u"NAME BURGER KING#2268 d <br /> 1J <br /> SrrE ADDRESS 619 W. MARTIN LUTHER KING JR-Wfflf STOCKTON 95206 <br /> Street Number10frection Street NaeZia-Code <br /> HDMEorNWLINGADDRESS (If Different from,SiteAddress) 1904 VIA DISALERNO <br /> Street Number, S"et Name <br /> CITY PLEASANTON STATE CA Z'P 94566 <br /> PHONE#'I Etr• APN# LAND USE APPLICATION# <br /> (:209 ) 463 2003 14707210 <br /> PHONE 92 EXT• g¢gg pp�� 7RICT LOCATION CODE <br /> 15101 5735905 UU1-VI�LLAPUDUA oi-srocK-rON <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr• <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. /J n <br /> APPLICANT'S SIGNATURE: DATE: '.02102113 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If.4PPLicANT 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 /> Qu,ts�°r <br /> JC�Q�M Wet" <br /> SS\I\ <br /> ACCEPTED BY: EMPLOYEE#: DATE: ..L —(3 <br /> ASSIGNEDTO: EMPLOYEE �O �yL�y�, DATE: '�r <br /> Date.Service Completed (if already completed): _ � SERVICE CODE: C.�f�. P/E: <br /> Fee Amount: Amount.Paid jZs. D!] Payment Date 1131113 j <br /> Payment Type 1hi Invoice# ; Check# . Received By: � <br /> EHD 48-02-0254 A3� z SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />