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i <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> d <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> Restaurant ' U� a ,^I °,) j <br /> v { <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS e <br /> McDonald's US LLC,Silvia Wytkind <br /> FACILITY NAME McDonald's <br /> SITE ADDRESS 3143 West Benjamin Holt Stockton 95219 F <br /> t <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2999 Oak Road,Suit 900 <br /> Street Number Street NqMe <br /> CITY Walnut Creek, STATE CA ZIP 94597 I <br /> I <br /> PHONE#1 ExT APN# LAND USE APPLICATION# j <br /> (916 ) 586 0946 100-170-05 P18-0703 ss <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Hala Ibrahim, Project Manager CHEcKlfBILLING ADDRESS❑ <br /> s <br /> a <br /> n <br /> • s <br /> BUSINESS NAME PM Design Group, Inc ( 925 222 1672 <br /> HOME or MAILING ADDRESS 3860 Broadway Drive, Suite 110 FAx# <br /> CITY American Canyon STATE CA ZIP 94503 t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, j <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 /> a <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: <br /> DATE: C - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <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 t <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 San . e it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V <br /> o <br /> h, FNVjR QUIIy C <br /> �AcryaFpgRo� �y <br /> 6 <br /> ACCEPTED BY: EMPLOYEE#: 2-13 DATE: g <br /> ASSIGNED TO: EMPLOYEE#: 6o2—t3 DATE: I <br /> Date Service Comp eted (if already completed): SERVICE CODE: Z 3 P E: - <br /> Fee Amount: Amount Pai /8C 6d Payment Date <br /> Payment Type Invoice# �O Check# q0 ,0SO Rec ved By: <br /> i <br /> EFID 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �i <br /> a <br />