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SAN JOAQUIN UOUNTY LI N VIRONMENTAL JMEAL'1'H LLPAH'1 MM N'1 <br /> SERVICE REQUEST <br /> Type of Buslness or Properly FACIL RY ID S ERV CE REQUEST# <br /> Fast Food Restaurant <br /> OWNER/OPERATOR <br /> PRB Management, LLC CNECK II BIL PGADDREasI X <br /> FACIWYNAME Taco Bell - Remodel <br /> SrtEADDREss W Hammer Lane -Stockton 95320 <br /> - 532 SVM Nlun6er L. n J t Nemo CI <br /> Home or maiLvib ADnRFss or nllforant from seta Addmast 4709 <br /> PRB Management, LLC au.peName.r Mangels Blvd. <br /> CITY FairField cCA 94534 <br /> pump All / Exr. APN# two USE APPLICATION a <br /> (707) 804 - 2919 <br /> PRORE42 Ext. SOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/SERVICE REQUESTOR _ <br /> REGUESTOR <br /> CHECK IfBaLEmADDRESS <br /> BU$mE35 NAME i.A A r 1, --2&000 <br /> Home or MmuNe�ADORES�i <br /> ^ �{ 5 _'AEA ) <br /> FF <br /> CITY c�N - STATE CA "P git401 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and 0E laws. <br /> APPLICANT'S SIGNATURE:_ 2/15/2022 <br /> DATE: <br /> PROPERTY/BUSINESS OWNER OPBRATOR/MANAGER L.1 OTHER AUTHORIZED AGENT❑ <br /> IfAPPLlcAArr is not the BxU,VG PAK7Y proof of authordaadon 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 environmental/site assessment <br /> informafion 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: Plan check PcNr <br /> Coulmor3: p <br /> Electronic <br /> EB 17 201? <br /> SAN JOAQUI <br /> HEgLTH ONIAENTANTY <br /> OEPARTIl1E <br /> ur <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DAZE: 2-17-22 <br /> ASSIGNED To: Vidal Pedraza EMPLOYEE#: 6213 DATE: 2-17-22 <br /> Date Service Completed (R already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Pal — dd Payment Date -2//& 2— <br /> 2 <br /> Payment Type invoice# Chock# /31 OS-0&cl 7 Race By: _1 <br /> EHD 43-D2.025 Ment confirmation# 139050697 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 payment <br />