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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> McDonald's Restaurant ::::[ FAOON3 <br /> V 5400-7b ( <br /> OWNER/OPERATOR G� 1 ,1 <br /> McDonald's USA, LLC-Contact Deanna Uecker CHECK I(BILLINO ADDRE89❑ <br /> FACILITY NAME <br /> SITEADDRESS 1382 West Colony Road Ripon 95366 <br /> oftetwMIN, e <br /> HOME or MAILING ADDRESS (U Different from Site Address) 2999 Oak Road S~NAM <br /> Number <br /> CITY Walnut Creek STATE CA ZIP 94597 <br /> PHONE#11 EKT• APN# LAND USE APPUcAnONIt <br /> ( 209 ) 281-9721 261-59-010 <br /> PHONE#2 EKT. BOS DISTRICT LOCATIOKCODE <br /> t ) WW OS <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Zorah Mariano CHECK H BILLING Apogees <br /> BUSINESS NAME PHONE# E'<T' <br /> Stantec Architecture 9NE 669-5928 <br /> HOME or MAILING ADDRESS FAx# <br /> 555 Capitol Mall, Suite 650 1 ) <br /> CITY Sacramento STATE CA ZIP 95814 <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,Slandaro,-S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/13/2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENTif Design Lead <br /> If APPLICANT is n the G PARTY proof of authorization to sign is required Tule <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. P <br /> TYPE OF SERVICE REQUESTED: Food Service Plancheck <br /> COMMENTS: <br /> Scope of work: Interior TI;ADA Upgrades; Counter Change. DEC ' 4 2017 <br /> No kitchen scope of work. SANJOAQUI <br /> NCAL CArVHIRolviti DCPARTT- TY <br /> MCNT <br /> ACCEPTED BY: ri 0+,E1EMPLOYEE 0: DATE: <br /> ASSIGNEDTO: qn EMPLOYEE DATE: -H-1 <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: <br /> Fee Amount: 9 576 oo Amount Pa (-� / 00 Payment Date <br /> Payment Ty Invoice# Ch-76 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />