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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 /> CHECK If BILLING ADDRESS <br /> Brian McCarthy <br /> FACILITY NAME <br /> McDonald's LLC <br /> C <br /> Hammer Ln. Stockton 95 C2$ITE ADDRES s �55:33 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)952-7693 126-180-070 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Yao - myao@core-states.com CHECK If BILLING ADDRESSID <br /> BUSINESS NAME - PHONE# EXT. <br /> Core States Group (909)467-8937 <br /> HOME Or MAILING ADDRESS FAX# <br /> 4240 E. Juru a St. ( ) <br /> CITY Ontario STATE CA ZIP 91761 <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: September 17, 2019 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager <br /> IfAPPLICANT 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same me it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: Expedited Health Plan Review of Existing McDonalds EC T <br /> COMMENTS: ®Cr O <br /> New front counter, full dining remodel, ADA remediation in restrooms, no kitchen scopes NUAQutN 019 <br /> HCo <br /> p pM �)Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: top DATE: O <br /> ASSIGNED TO: EMPLOYEE#: ^ 2 DATE: f VO <br /> Date Service Completed (if already Completed): SERVICE CODE: n �Z `P/ : <br /> Fee Amount: + Amount Paid too , Payment Date ID <br /> Payment Type 7 Invoice# Check# (036 760 Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />