Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Commercial/Restaurant 2-01 0 3 S� DLI`�YJZ <br /> OWNER/OPERATOR <br /> Red Robin Intemational ��A.t-yl <br /> W�f �� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Red Robin Gourmet Burgers& Brews <br /> SITE ADDRESS 873 1 Lifestyle Manteca 95337 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2252 E GIIwood <br /> 2252 Street Number Street Name <br /> CITY Stow OH 44224 ZIP 44224 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (330 ) 907-9893 22y D <br /> PHONE#2 Ems. BOS DISTRICT LOCATION CODE <br /> (380 ) 714-2993 00 0''1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Zech Milush CHECK If BILLING ADDRESS El <br /> BUSINESS NAME Ex . <br /> Badger Expediting LLC PH41Fb# 907-9893 <br /> HOME or MAILING ADDRESS 2252 E Gilwood Drive FAx# <br /> CITY Stow STATE OH ZIP 44224 <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: 6/2/21 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Owner <br /> If APPLICANT is not the BtLLINGPARTY proofof authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 environinental/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: h V'Z+. y,,1 e . is <br /> COMMENTS: Z r Q�5 /� C O A/rG <br /> �l2ch'IT" r � l TC(INI, AAAUUA///"""KKK( /1 U ?0 <br /> S fIyOAQUM/CQUN <br /> ACCEPTED BY: C f,�tA-r--JGa EMPLOYEEM DATE: � ' _2 ! <br /> ASSIGNED TO: �IA/"h EMPLOYEE#: DATE: — t ( -2 / <br /> Date Service Completed (if already completed): SERVICE CODE: '5 Z3 P 1 E: <br /> Fee Amount: i" Amount Paid Payment Date <br /> Payment Type Invoice# 1 2(q Received By: <br /> EHD 4"2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />