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} " SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />Stantec Architecture Inc. <br />CGMMENTS: <br />SERVICE REQUEST # <br />Quick Serve Restaurant <br />_ 6d 1 / <br />(� <br />CITY Petaluma <br />Slt 00-19 /0 (n <br />OWNER / OPERATOR <br />�tN7C <br />FACTy0F <br />CHECK If BILLING ADDRESS❑ <br />Deanna Uecker/ McDonald's USA LLC <br />NNkfiNry <br />FACILITY NAME <br />TMFNT <br />McDonald's #004-3481 Stockton - Hammer & Don <br />ACCEPTED BY: <br />SITEADDRESS <br />W <br />I <br />Hammer Ln. <br />DATE:C� {r T �. ! <br />Stockton <br />95209 <br />2415 <br />DATE: / I <br />Date Service Completed ( already completed): <br />SERVICE CODE: z, <br />Street Number <br />Direction <br />Street Name <br />4L,56, �� <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Oak Road <br />2999 Street Number <br />Received By: <br />Street Name <br />CITY Walnut Creek <br />STATE CA ZIP 95497 <br />PHONE #1 Err. <br />APN # <br />LAND USE APPLICATION # <br />(209 )281-9721 <br />075-420-030-000 <br />PHONE#2 Err. <br />( ) <br />BOS DISTRICT, O� <br />V <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Robert Picard/Stantec Architecture Inc. <br />CHECK H BILLING ADDRESS ET <br />BUSINESS NAME <br />Stantec Architecture Inc. <br />CGMMENTS: <br />PHONE# En' <br />707 774-8327 <br />HOME or MAILING ADDRESS <br />1383 N. McDowell Blvd. Ste 250 <br />FAX# <br />( 1 <br />CITY Petaluma <br />STATE CA ZIP 94954 <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 pre;,are and that the wor o be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, St ndan F ERALlawAPPLICANT'S SIGNAT DATE: 5/07/2018 <br />PROPERTY / BUSINESs OWNER❑ O / NAGER ❑ OTHER AUTHORIZED AGENT ❑IfAPPLICANT is notG AR proof of �authorizaflori t0 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 environmentallsite assessment <br />information to the SAN JOAQUIN COUNTY ENV020NMENTAL HEALTH DEPARTMENT as soon as it is available and at te time it is <br />provided to me or my representative. An_ 4ri/cA <br />TYPE OF SERVICE REQUESTED: r <br />�� <br />CGMMENTS: <br />14* <br />J , L 1018 <br />�tN7C <br />FACTy0F <br />NNkfiNry <br />TMFNT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE:C� {r T �. ! <br />ASSIGNED TO: r <br />EMPLOYEE #: '106 S(CF <br />DATE: / I <br />Date Service Completed ( already completed): <br />SERVICE CODE: z, <br />PIE. b b <br />Fee Amount: <br />Amount Paid <br />4L,56, �� <br />Payment Date <br />S/ `g <br />Payment Type- <br />Invoice # <br />Ch <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />