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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RESTAURANT � ��`�`;L <br /> OWNER I OPERATOR PANERA BREAD, LLC, CHECK If BILLING ADDRESSO <br /> fAGurvNAME PANERA BREAD #1959- STOCKTON, CA <br /> SITE ADDRESS 8932 PACIFIC AVENUE STOjC �ON 95207 <br /> Street.Number DII. tion Street.Name <br /> Zip Gods <br /> HOME or MAILING ADDRESS (if Different from Site Address) 3630 S. GEYER ROAD <br /> Street Number Street N e_ <br /> CITY SUNSET HILLS STATEMO zIP 63127 <br /> PHONE#t <br /> ExT.. I APN fj LAND USE APPLICATION# <br /> (314)384-2525 <br /> PHDNE#2 EXT;- BOS D15TR1CT LOCATION CODE <br /> 4 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> I` REQU"'RARTHUR OSTROWSKI CHECK if BILLING ADDRESS® <br /> BUSINESS(NAME PHONE# E'T' <br /> NORR 312 873-1067 <br /> HOME or MAILING ADDRESS 325 N. LASALLE STREET SUITE 500 FA"# <br /> (312) 576-2683 <br /> CITY CHICAGO STATE IL ZIP 60654 <br /> I - <br /> 131LLiNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVJRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />!t 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 /> l COUNTY Ordinance Codes,Standards,Sp'I'r.and FEDERAL laws. <br />�. APPLICANT'S SIGNATURE: `r= DATE:. 02/17/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER CI OTHER AUTHORIZED AGENT® - DESIGNER - - <br /> i IfAfPLICANT is not the BILLING 1 ART);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 itis available and at tie same time it is <br /> provided to me army representative. ' X <br /> TYPE OF SERVICE REQUESTED: F� <br /> �} <br /> � T r <br /> COMMENTS: y F 0A4U Ala/ <br />� k <br /> Q?' <br /> N. <br /> I <br /> ACCEPTED BY: EMPLOYEE#: DATE:a 17 <br /> , - <br /> ASSIGNEDTO: Z. EMPLOYEE DATE:a . / <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> 11E, <br /> } ! Fee Amount: Amount Pa 3`�'d,D� Payment Date 7 1 <br /> Payment Type V1, Invoice# Check# z,46q3Received By: <br /> EHD 45-02-025 % SR FORM(Golden Rod) <br /> I REVISED 111117/2003 <br /> d - _ <br /> I � <br />