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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Full service restaurant , <br /> OWNER/OPERATOR Blazin Wings Inc CHECK If BILLING ADDRESS El <br /> FACILITYNAME Buffalo Wild Wings <br /> SITEADDRESS 2796 Naglee Road Tracy 95304 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 Glenlake Pkwy NE <br /> Street Number Street Name <br /> CITY Atlanta STATE GA ZIP 30328 <br /> PHONE#1 Ext' APN# LAND USE APPLICATION# <br /> (678 )514-4100 212050600 N/A <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR/APPLICANT <br /> REQUESTOR Mindy Bernard CHECK If BILLING ADDRESS <br /> BUSINESS NAME CDS Development Services (PHONE0 370-0943 <br /> HOME or MAILING ADDRESS 14901 Quorum Drive, Suite 310 FAx# ) N/A <br /> CITY Dallas STATE TX Zip 75254 <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: Mindy J Bernard - DATE: 04/29/2021 <br /> PROPERTY/BUS[NESS OWNER❑ OPERATOR/MANAGER ❑ ....OTHER AUTHORIZED AGENT IN Property Dev. Coordinator <br /> IfAPPLICANT is not the BiLLtNG PARTr 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 an*tthe same time it is <br /> provided to me or my representative. A y <br /> TYPE OF SERVICE REQUESTED: ZZOA, JqZA— <br /> COMMENTS: V4% 21 <br /> h A STN fc1/M,AUNTY <br /> QRTMENT <br /> ACCEPTED BY: EMPLOYEE#: Z� 3 DATE: Z <br /> ASSIGNED TO: EMPLOYEE M 1/ DATE: ^7 I <br /> Date Service Completed (if already completed): SERVICE CODE: O F2-3 P 1 �'/ <br /> Fee Amount: 11s Amount Paid �� Payment Date Z� <br /> Payment Type ' In�vo�iceee# Check# 1 Z`�-SS Receiv d By: <br /> EHD 48-02-025 11/17/2003 �(/'�II�`'Cittl.t, rjQj(;� 2�7 J'9 I�� SR FORM(Golden Rod) <br /> REVISEDEDi1/100 <br /> �Rc522`7�� 5 <br />