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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ��ff FACILITY ID# SERVICE REQUEST# <br /> Restaurant FAUx Li 12 <br /> OWNER I OPERATOR <br /> CHECK If BILUNO ADDRESS <br /> RED ROBIN GOURMET BURGERS <br /> FACILITY NAME <br /> RED ROBIN GOURMET BURGERS&BREWS <br /> StTE ADDRESS 5202 PACIFIC AVENUE STOCKTON 95207 <br /> Street Number I DiroctIon Stryet Name city ZIp code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6312 S.FIDDLERS GREEN CIRCLE SUITE 200 NORTH <br /> Suse Mroot Nsimt <br /> CITY STATE zip <br /> GREENWOOD VILLAGE CO 80111 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (303 ) 846-5446 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> BRAD SMITH CHECK If BILLING ADDRESSll <br /> BUSINESS NAME PHONE# En' <br /> RED ROBIN GOURMET BURGERS 303 846-5446 <br /> HOME Or MAILING ADDRESS FAx# <br /> 6312 S.FIDDLERS GREEN CIRCLE,SUITE 200 NORTH ( ) <br /> CITY GREENWOOD VILLAGE STATE CO ZIP 80111 <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 an"the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and r`F DORAL law <br /> Z 9/17/2015 <br /> APPLICANTS SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP %MANAGI U--w OTHER AIMIORIZED AGENT❑ PROPERTY DEVELOPMENT MANAGER <br /> IfAPPLICANT is not the BILLING PART},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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -1'lce pAYMEN <br /> COMMENTS: <br /> SEP 2 2 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL_ T <br /> HEALT}I DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE M DATE: e L I C;- <br /> ASSIGNED <br /> ASSIGNED TO: f 1(�� " �41'i .� EMPLOYEE M DATE: 9'-L? /T; <br /> Date Service Completed (if already completed): SERVICE CODE: ,1, 23 PIE: <br /> Fee Amount: U CZ. Amount Paid 3 -Ir C9 C/ Payment Date Cl <br /> _ <br /> Payment Type G Invoice# Check# t( S Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />