Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> McDonald's Restaurant C6Q,06 7L11�J <br /> OWNER/OPERATOR <br /> McDonald's of San Joaquin County CHECK if BILLING ADDRESS® <br /> FACILITY NAME McDonald's <br /> SITE ADDRESS 1613 Lower Sacramento Road Lodi 95242 <br /> Stmet Number I Diroeaon Stmet Nom city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5402 Georgetown Place <br /> Street Number Stmet Name <br /> CITY Stockton STATE CA ZIP 95207 <br /> PHONE 91 Ex . APN# LAND USE APPLICATION# <br /> (209) 938-1225 5 <br /> PHONE#2 Exr BOB DISTRICT <br /> FU NC LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Benjamin Barrett - Project Manager CHECK if BILLING ADDRESS <br /> BUSINESS NAME VI en Incorporated PHONE# E *. <br /> 9 P 559 268-2711 <br /> HOME or MAILING ADDRESS FA%# <br /> 516 W. Shaw Ave, Suite 101 ( ) <br /> CITY Fresno STATE CA LP 93704 <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 DERAL laws. <br /> APPLICANT'S SIGNATURE: 4r DATE: 2/1/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER L,! OTHER AUTHORIZED AGENTO Architect of Record <br /> IfAPPLIcANT is not the BtLL/wGPARTY proof of authorization to sign is required Titte <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. AqY <br /> TYPE OF SERVICE REQUESTED: ZGK— CF/VEO <br /> COMMENTS: EA; ' <br /> 'W <br /> 00Eyr14ry <br /> '''w EHr <br /> ACCEPTED BY: rn EMPLOYEE#: DATE: 2 — I j <br /> ASSIGNED TO: EMPLOYEE#: DATE. / —/ <br /> Date Service Completed tit already completed): SERVICE CODE: P/E: 11�oj <br /> Fee Amount: ago.O1% Amount Pal 3qo 00 Payment Date /I <br /> Payment Type ✓ Invoice# Check# /373 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />