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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 T-A Oa2 )�6' 4Ge <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> Deanna Uecker <br /> FACILITY NAME <br /> McDonald's LLC <br /> SITE ADDRESS W Lathrop Rd. Manteca 95336 <br /> 1137 Street Number Direction Street game city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ve <br /> nr�A <br /> 601 Street McHe <br /> Number Stree, e <br /> CITY STATE ZIP <br /> Modesto CA 95350 Y ENT <br /> PHONE#1 APN# LAND USE APPLICATION# VED <br /> (209)825-8518 197-240-020-000 <br /> i �Oftjl. <br /> PHONE#2 En. BOS DISTRICT LOCAiIp,N CODE 2019 <br /> CONTRACTOR/ SERVICE REQUESTOR MEalrHo fP Q 'r L n" <br /> REQUESTOR ENT <br /> Mike Yao - myao@core-eng.com <br /> CHECK If BILLINGADDRESS❑x <br /> BUSINESS NAME PHONE# En. <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: May 8th, 2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager <br /> IfAPPL1CAVT is not the B/LL/NGPARTr 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 HEALTH 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: Health Plan Review of Existing MCDOnalds <br /> COMMENTS: <br /> New front counter, new order menu wall with (5) menu boards, new service area tile, new kiosk. <br /> New lobby decor and ADA remediation in the bathrooms, replacing existing bathroom fixtures like <br /> for like in the same place. NO Kitchen scope. <br /> ACCEPTED BY: EMPLOYEE M 21 3 DATE: G <br /> ttq <br /> ASSIGNED TO: EMPLOYEE M DATE: 1. <br /> Date Service completed (If aMady completed): SERVICE CODE: !'y� P IE 1(001 <br /> Fee Amount: 6 Amount Paid 7Z)(0,0 D Payment Date <br /> 40 <br /> Payment Type Invoice# Check If 91DReceived By: <br /> EHD 48-02-025 7 w4%Ll SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��`i3toZo <br />