Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property y66L9-AAf- <br /> FACILITY ID# �S�ERRVIIICCE REQUEST# <br /> Restaurant Sgwov 6;q <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Deanna Uecker <br /> FACILITY NAME <br /> McDonald's LLC <br /> SITE ADDRESS <br /> 1613 S Lower Sacramento Rd. Lodi 95242 <br /> Sheet Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) O <br /> 1556 Street Number P SfreSt fJm Pr. <br /> CITY STATE ZIP <br /> Walnut Creek CA 94596 <br /> PHONE#1 EKr APN# LAND USE APPLICATION# <br /> (209)281-9721 058-030-280-000 <br /> PHONE#2 EKT BO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Yao - myao@core-eng.com <br /> CHECK if BILLING ADDRESS x <br /> BUSINESS NAME PHONE# E" . <br /> Core States Group (909)467-8937 <br /> HOME or MAILING ADDRESS FAX# <br /> 4240 E. Juru a St. ( ) <br /> CITY Ontario STATE CA ZIP 91761 <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 forth. <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 /> APPLICANT'S SIGNATURE: DATE: April 10, 2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORtzEDAGENT® Project Manager <br /> IfAPPLicANT 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 s; . .S <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Health Plan Review Of Existing MCDOnalds 7J� Al COMMENTS:New front counter, new order menu wall with (5) menu boards, new service area tile, r�NO Kitchen scope, NO bathroom scope TH0% £ <br /> T <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: 10 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 PIE: ' I <br /> Fee Amount: Itao Amount Paid ¢ 6 Payment Date ifll' 41 <br /> y <br /> Payment Type S Invoice# C}1h�eck# Received By: <br /> EHD 48-02-025 'n p `�" "�w gy 9 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 'VI( ar"d o' <br />