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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property e$ 1FACILITY ID# QSERVIC(EE REEQJUIE/S'T'# <br /> . «. ... .. ... .... ....«M•MNN•w•wN• S V 1S ✓'V` 0 <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDR SS <br /> • II N•1 •N • • •NN • •N . . . . . . . . .. . . . . . . . . . . . . . . . . • • <br /> FACILITY NAME <br /> SITE ADDRESS /S/dy•••• -Dim <br /> • D�� Ca.�dyli •�dE-« • •«............ L4S�K4 • «N.N.• <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Differept <br /> hiIldfrom S'te Ad�lrleSS) <br /> 4 Stm Number Street Name <br /> CITY • .. r w • «w««I.• 'I� STATE.n yl ZI � ' ,? /6 /a2V I � l!.Tl T...� (P <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925) 719-2883 19611029 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alicia Maldonado CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Marks Architects 619 702-9448 <br /> HOME or MAILING ADDRESS FAX# <br /> 2643 4th Ave ( ) <br /> CITY San Diego STATE CA z'P 92103 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4&G /ffaldoKado DATE: 4.29.2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTO Project Manager <br /> If APPLICANT is not the BILGING 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: Plan review for new restaurant REQ IVICIVr <br /> COMMENTS: New 1690sf drive thru restaurant. MAY 05 I�rrll <br /> SAN jDAQUIN �YZQ <br /> HEALTOUNTy <br /> H DE qR M NT <br /> ACCEPTED BY: EMPLOYEE#: GJ DATE: <br /> ASSIGNED TO: a- S�f l L EMPLOYEE M y' DATE: J/_ l <br /> 5 it <br /> Date Service Completed (if already completed): SERVICE CODE: 5�,3 P/E: I(d�/r <br /> Fee Amount: �� �� Amount Paid j�,to Payment Date SsD <br /> Payment Type Invoice# Check# /o$/S 7� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 U rpt J QGt�( <br />