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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QS restaurant _ Zy qy- 5,go0 (0. <br /> Q SE4 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> WINGSTOP <br /> SITE ADDRESS <br /> 1988 Street Number DirectionWEST 11TH STREET Street Name TRACY 95376 <br /> Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1063 CHESHIRE CIRCLE <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> DANVILLE, CA 94506 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (925 ) 260-3605 <br /> PHONE#Y EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 15/22/2013 <br /> PROPERTY/BUST NESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ V.PRESIDENT <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 t0 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: fVED <br /> COMMENTS: <br /> APR 2 5 2013 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: A4 EMPLOYEE#: DATE: / <br /> ASSIGNED TO: ktt <br /> / Gl hf I EMPLOYEE#: l V- '7i� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C G I PIE: 16O 2— <br /> Fee <br /> Fee Amount: 4'1'Z Amount Paid -D� Payment Date /f3 <br /> Payment Type Invoice# Check# D D 3 Received By: 2� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />