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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant <br /> OWNER/OPERATOR <br /> Kyong S. Kim CHECK if BILLING ADDRESS <br /> FACILITY NAME Dickey's Barbecue Pit Restaurant <br /> SITE ADDRESS 15338 S. Harlan Road Lathrop, CA 95336 <br /> Street Number Direction Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 965 Golden Pond Drive <br /> Street Number Street Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510 ) 972-1919 (C, � I I C I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) V T7 't u I'll 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> TBD CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 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,STAT nd FEDERAL laws. /' ff 11 <br /> APPLICANT'S SIGNATURE: 4 DATE: Z <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ff APPL/CANT 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,HFAI_.TH 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: `(M^ (J <br /> COMMENTS: V zo I�iOO� !r4 L��� y <br /> RECEIVED <br /> APR 2 S 20% <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: L EMPLOYEE#: DATE: <br /> —� b��L L 14 Zi (4� <br /> ASSIGNED TO: V i S ( vim EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: ) v <br /> Fee Amount: Amount Paid , Payment Date jt <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />