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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property pp FACILITY <br /> c-IID/#� SERVICE REQUEST#(� <br /> Restaurant �j-I C 0(ZOO �5 (� <br /> OWNER/OPERATOR <br /> McDonald's USA LLC CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> McDonald's 004-0428 Lower Sacramento <br /> SITE ADDRESS 8020 Lower Sacramento Rd. Stockton 95210 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 ) 079-490-05 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Deanna Uecker <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME McDonald's USA LLC PHONE# EXT. <br /> 209 281-9721 <br /> HOME or MAILING ADDRESS 2999 Oak Road FAX# <br />? CITY Walnut Creek STATE CA ZIP 94597 <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan STA and FEDERAL I S. <br /> APPLICANT'S SIGNATL DATE / / <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f.-IPPL/CAA'T is not the BILLING PARTY,proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator oft he pr eerrty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environ n4� f�sessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an <br /> '� It IS <br /> provided to me or my representative. _e�9 <br /> TYPE OF SERVICE REQUESTED: Plan Review / <br /> If <br /> COMMENTS: ENV,AQ(/lN(; <br /> H�CTy E M� ��)Y <br /> T <br /> ACCEPTED BY: Q 1 EMPLOYEE#: —75 4 1 DATE: `1 t 1-7`7 <br /> ASSIGNED TO: C/` n EMPLOYEE#: OQ DATE:LX Ca (J I <br /> Date Service Complete (if already completed): R.` SERVICE CODEv JC P 1 E: 1` <br /> Fee Amount: �6DO Amount Paleqls-6 Payment Date <br /> Payment Type V,40-- (� Invoice# Ch k# / Z Recei ed By: <br /> EHD 48-02-025 � DdSI �fi SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />