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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE PEQUEST# <br /> Quick Serve Restaurant <:��, 00111 <br /> OWNER/OPERATOR <br /> Deanna Uecker/ McDonald's USA LLC <br /> CHECKIfBILLINGADDRESS <br /> FACILITY NAME McDonald's #004-1916 Tracy #2 <br /> SITE ADD182REOSS W Eleventh Street Tracy 95376 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Oak Road <br /> 2999 Street Number Street Name <br /> CITY Walnut Creek STATE CA ZIP 95497 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 281-9721 234-020-170-000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Robert Picard / Stantec Architecture Inc. <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Stantec Architecture Inc. PHONE# EXT. <br /> 707 774-9721 <br /> HOME or MAILING ADDRESS FAX# <br /> 1383 N. McDowell Blvd. Ste 250 ( ) <br /> CITY Petaluma STATE CA ZIP 94954 <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 prepa t t lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S ndards,ST and FE12L la <br /> APPLICANT'S SIGNATUR DATE: 06/19/2018 <br /> PROPERTY/BUSINESS OWNER❑ OP R/ AGER ❑ OTHER AUTHORIZED AGENT❑ Area Construction Manager <br /> If APPLICANT is not the BILLING PARTY proof of authorization 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 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. w <br /> TYPE OF SERVICE REQUESTED: l Ay <br /> COMMENTS: <br /> �G� ✓ tic vt�-�- JUN? D <br /> SAN Jo 9 ?018 <br /> FN AQUI <br /> y,� C HOE eAIO /Vn' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: f—Z3 P I E: <br /> Fee Amount: 46 Amount Pai do Payment Date <br /> Payment Type ��_ Invoice# Ch ck"� ? 5�3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> V-0 lig�3�2 <br />