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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =SERVICEQUEST# <br /> Restaurant and drive-through 7(p� <br /> OWNER/OPERATOR panda Express, INC. CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME panda Express <br /> SITE ADDRESS 15099 S. Harlan Road Lathrop 95330 <br /> Street Number Direction Street Name I city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1683 walnut Grove Avenue <br /> Street Number Street Name <br /> CITY Rosemead S STATE CA Zip 91770 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (916 ) 451 1500 ( 107 196-110-01;-02;-03;-04; <br /> I <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> i <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR TBD CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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,STA " and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BLSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ iAuA(a7--/2 <br /> /f 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 pr located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/ore a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMF.N"1"AL HEALTH DEPARTMENT as soon as it is av �Idazd <br /> me time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �`N GOut- <br /> sl,3°*QCN14 P��M� � <br /> NOW <br /> i <br /> i <br /> ACCEPTED BY: � EMPLOYEE#: DATE: cj I� j <br /> `—( <br /> ASSIGNED TO: ` 1/v 2 EMPLOYEE#: DATE: — I S <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: — L' U Amount Paid Payment Date g Z� 1� <br /> Payment Type I�«(L Invoice# Check# 1489 2O1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �l <br /> I <br />