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mtl+CIYt U <br /> e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SEP 3 0 2016 <br /> SERVICE REQUEST iNVIRONMENTALHEA, TH <br /> CE5 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> New Drive Thru Restaurant �F}t�p6�a 7 �pO 7�jq <br /> OWNER/OPERATOR <br /> Joseph Sadek CHECK if BILLING ADDRESS <br /> FACILITY NAME Farmer Boys <br /> SITE ADDRESS 2312 West Kettleman Lane Lodi 95242 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5370 Dunlop Drive <br /> Sheet Number Street Name <br /> CITY Riverside STATE CA ZIP 92505 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 951 ) 662-7369 058-14048 <br /> PHONE f/2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR Jerry Mercado CHECK If BILLING ADDRESS <br /> BUSINESS NAME HC&D Architects, Inc. PHONE# ExT. <br /> 951 371-2057 227 <br /> HOME or MAILING ADDRESS 1801 Lampton Lane FAx# <br /> p ( 951 ) 371-5924 <br /> CITY Norco STATE CA ZIP 92860 <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 /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 09-29-2016 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® HC&D Architects, Inc. <br /> IfAPPLLCANT is not the BLLLLNGPARTf 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 /> (� ry <br /> TYPE OF SERVICE REQUESTED: bd '[ `Q VA C — cR ryT <br /> COMMENTS: Expedited plan review for Health Department Plan Check SFp 3 O F0 <br /> y '0 <br /> -1 if <br /> 4 Q01* <br /> �s <br /> 4kA r <br /> ACCEPTED BY: EMPLOYEE#: DATE:�,7� I <br /> ASSIGNED TO. ,rC-� EMPLOYEE#: DATE: C <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: �aGJ- Amount Pa' (> Payment Datej <br /> Payment Type I/ Invoice# Check# �D� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 p <br />