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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property T,A FACILITY ID# SERVICE REQUEST# <br /> Restaurant/McDonald's 0002- 7-2- Syz uoo Z(. <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Golden Arch Realty Corporation <br /> FACILITY NAME <br /> McDonald's <br /> SITE ADDRESS <br /> 95210 <br /> 8020 Street Number I Direction Lower Sacramento 114.et Name Stockton city ZipCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) Enco Dr. <br /> 2111 Street Number Street Name <br /> CITY Oak Brook STATE IL Zip 60521 <br /> PHONE 91 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 281-9721 07949005 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Architect/Kerry Shahan CHECK If BILLINGADDRESSa <br /> BUSINESS NAME PHONE# ExT' <br /> ACG Design 1 702 931-2992 <br /> HOME or MAILING ADDRESS FAx# <br /> 4310 Cameron St.Suite 12-A ( ) <br /> CITY Las Vegas STATE NV ZIP 89103 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN r <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: awkc) DATE: 2/22/2019 <br /> PROPERTY'/BUSINESS OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Architect <br /> IfAPPLICANT is not the BILLING PART}',proof of to to sign is required Time <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. <br /> TYPE OF SERVICE REQUESTED: to <br /> IV <br /> COMMENTS: ��� <br /> �01 <br /> TN OQpMFNTUN7'Y <br /> q,TT41 <br /> Al <br /> ACCEPTED BY: CL-k S C EMPLOYEE#: DATE: • <br /> ASSIGNED TO: t � EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: S ) P1 E: f 6 <br /> Fee Amount: u 5 Amount Pal .0-6 Payment Date <br /> Payment Type Invoice# C ck# S�ji/�-79Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />