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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property CILITY ID# SERVICE REQUEST# <br /> McDonald's Restaurant 1 S2- C)0 1-7tJ /1069 <br /> OWNER/OPERATOR McDonald's USA, LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME McDonald's <br /> SITE ADDW. Banner Street Lodi 95242 <br /> Street Number Direction Street Name Cit 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 /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Anna Doan <br /> CHECK 11 BILLING ADDRESS <br /> BUSINESS NAME Core States Group PHONE# Exr. <br /> 909 467-8914 <br /> HOME Or MAILING ADDRESS 4240 E.Jurupa Street, Suite 402 FAx# <br /> CITY Ontario STATE CA ZIP 91761 <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,Standard,"TATE nd VFDERAL laws. <br /> APPLICANT'S SIGNATURE: �V 1, DATE: 02/06/2018 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,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 sar>easr, e it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ec-{YbYI ('c- Su <br /> y�R qR��q�Nt Y <br /> MFtiT <br /> ACCEPTED BY: lNu�s EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: �� r <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid,413040,/-) Payment Date 71 S <br /> Payment Type of Invoice# Ch k# ��D�O� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />