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�. 1h <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QUICKSERVE RESTAURANT WI DRIVE THRU ��. (✓, Z, c� ya <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> II SUNNY GHAT,PRESIDENT QUICKSERVE ENTERPRISES INC. <br /> FACILITY NAME <br /> BURGER KING RESTAURANT <br /> SITE ADDRESS 619 'WEST CHARTER WAY STOCKTON 95207 <br /> Street Numbol Direction Street Name 0L Z1p Code <br /> WOME or MAILING ADDRESS (If Different from Site Address) . <br /> - Street Number .Street Name. <br /> CITY 1905 VIA DI SALERNO;PLEASANTON,CA 94566 STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> { ) <br /> 1,511114911-5101, ` <br /> PHONE#2 FXT• BOS.DISTRICT LOCATION CODE <br /> i ) S S�J sqon <br /> 4. CONTRACTOR /.SERVICE REQUESTOR <br /> r' REQUESTOR <br /> SUNNY GHAI,PRESIDENT CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME QUICKSERVE.ENTERPRISES.INC. PHONE# (510)490-5001 Exr. <br /> HOME or MAILING ADDRESS 1905 VIA DI SALERNO,PLEASANTON,CA-94566 FAX# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT. 1, the undersigned property or Business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific!ENVIRONMENTAL HeAILTIT Dr-PARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this:form. <br /> .also certify that I have prepared this application anPtIhitl work to.beperformed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes..Standards.STATE d • vs. <br /> APPLICANT'S SIGNATURE: DATE:. 1131!13 <br /> IPROPER'tl'/BLISINESSO%A'N°ERIM OPERATOR A,'AGLR ❑ OTnuHAtrnloluZEDAGt'NT❑ <br /> IfAPPLIC4NT is not the BILLL:'C;PARTY.Proof of authorizatioir to sign is required Title <br /> AUTHORIZATION TO RELEASE INI~ORMATION: 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 and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAI.IIFNI,TH 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: 3 - M pAYMENT <br /> COMMENTS: R EC E <br /> WLU <br /> SANSAN JOAQUIN COUNTY <br /> VAOkLTH OEPpRTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: j v r '� EMPLOYEE#: DATE: — 3/ —/-3 <br /> ( S(-.14f... <br /> Date Service Completed (if already completed): SERVICE CODE: Z?f P!E: ! �� <br /> Fee Amount: 3 JrAmount Paid 1Q�S—� Payment Date ! 3 �3 <br /> Payment Type ✓ Invoice# Check# 0 R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> 1 <br /> t <br /> i' <br />