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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Wings R US LLC CHECK If BILLING ADDRESS <br /> FAcILm NAME <br /> Wingslop <br /> SITE ADDRESS 95210 <br /> 7910 1A Lower Sacramento Road Stockton <br /> Street Number I Dlrecllon Street Name city Zip 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#1 Err. APN# LAND USE APPLICATION# <br /> (925 ) 260-3605 <br /> PHONER Ev. BOS DISTRICT LOCATION CODE <br /> (209 )242-2341 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Wings R US LLC CHECK If BILLING ADDRESS <br /> BUSINESS NAME - PHONE# En. <br /> WINGSTOP <br /> HOME Or MAILING ADDRESS FAX# <br /> 1063 Cheshire Circle ( ) <br /> CITY Danville STATE CA Zip 94506 <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 /> I also certify that I have prepared this aln iication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,$TATE and UER laws. <br /> APPLICANT'S SIGNATURE: DATE: 03/17/20 <br /> PROPERTY/BUSINESS OWNER® /MANA R fte" ,OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 environmentalK/`Ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at 0'?!�e/}ime it is <br /> provided to me or my representative. R F <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Change of ownership from Sunny Hot Wings, Inc. to Wings R US LLC SANjoZ�?0 <br /> yEA 4 <br /> 'RoyOffPg4 <br /> T0�N�Y <br /> ACCEPTED BY: e ��-1— EMPLOYEE#: DATE: <br /> ASSIGNED TO: c 'm�� '� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52 P I E: <br /> Fee Amount: Amount Pai ��a DZ> Payment Date $ Za <br /> Payment Type Invoice# Check# lZDG'� Recei ed By: AL <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />