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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property z FACILITY ID # REQUESTORJOHN DODSON �SERVICE REQUEST # RESTAURANT O C" z PHONE # Exr_ OWNER/ OPERATOR 1 t l CHECK If BILLING ADDRESS ❑ AMIR SAHEBALZAMANY HOME or MAILING ADDRESS 1330 OLYMPIC BLVD I ( ) CITY SANTA MONICA FACILITY NAME ZIP 90404 BURGER KING Ttt ACCEPTED BY: EMPLOYEE#: SITE ADDRESS 7847 TAM O'SHANTER DRIVE STOCKTON 95210 Street Number Direction Street Name Ci ZI Code HOME or MAILING ADDRESS (If Different from Site Address) 2821 CROW CANYON ROAD Street Number Fee Amount Street Name Amount Paid , �5 (P , pp Payment Date STATE ZIP CITY SAN RAMON CA 94583 PHONE#1 EXT' APN# LAND USE APPLICATION# ( 925 ) 989-1195 094-030-38 PHONE#2 EXr. BOS DISTRICT LOCATION CODE 9 -"VTR Af TnR / RF.RVICF. REOUES'I'OR BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: (�/ L� DATE: 9-27-17 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ARCHITECT IfAPPLICA,VT is not the BILLING PARTP proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is I resentaLive provide to me or my rep - z if BILLING ADDRESS■ REQUESTORJOHN DODSON -0 G CHECK O C" z PHONE # Exr_ BUSINESS NAME ADNA 1 t l 310 452-5533 X204 HOME or MAILING ADDRESS 1330 OLYMPIC BLVD I ( ) CITY SANTA MONICA STATE CA ZIP 90404 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: (�/ L� DATE: 9-27-17 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ARCHITECT IfAPPLICA,VT is not the BILLING PARTP proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is I resentaLive provide to me or my rep - z TYPE OF SERVICE REQUESTED: -0 G O C" z COMMENTS:y� ()W --I 1 t l M ? w � � N n 2 p m ,I Cq Ttt ACCEPTED BY: EMPLOYEE#: DATE: l l ASSIGNED TO: \'] 0 EMPLOYEE #: DATE• 3 I / f Date Service Completed I already completed): SERVICE CODE: P / E: I U Fee Amount Amount Paid , �5 (P , pp Payment Date IL) L}. Invoice # Check # 11Lv2�R Received By:% Payment Type EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003