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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# EGQ' <br /> ERVICE REQUEST# <br /> RESTAURANT — M jZ�w3 <br /> OWNER/OPERATOR <br /> Scott Brown CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Chi otle Mexican Grill <br /> SITE ADDRESS 16542 Golden Valley Parkway Lathrop 95330 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 182566 Street Number Street Name <br /> CITY STATE ZIP <br /> Columbus Ohio 43218 <br /> PHONE#'I En. APN# LAND USE APPLICATION# <br /> (614 ) 318-7419 1 19204040 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ben Fiedler CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> FHA Architects 402 895-0878 1 <br /> HOME Or MAILING ADDRESS FAx# <br /> 14344 Y St#204 1 ) <br /> CITY Omaha STATE NE ZIP 68137 <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,Standar and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t DATe,05 JUN 2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® <br /> /jAPPL1CANT 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.HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: v(/ J " <br /> COMMENTS: <br /> SAN Jo �8 ?O10 <br /> PC( LJ� C _ HFA Tl1 pON U/11TV <br /> /� 'FPARTMEN <br /> 71 <br /> ACCEPTED BY: CCA' —s CV EMPLOYEE#: DATE: <br /> ASSIGNED TO: l� ,` ,ka^.5 EMPLOYEE#: DATE:/ J Irl D <br /> Date Service Completed (if already completed): SERNCECODE: 5`�il PIE: <br /> Fee Amoun . �, b� Amount Paid Y(L6(O,0Payment Date g <br /> Payment Type 011 Invoice# Check# O if 2 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />