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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property McDonald's Restaurant FACILITY ID # ___-- SERVICE REQUEST # -1/.) 8(9 3 2-1 OWNER / OPERATOR McDonald's USA, LLC CHECK if BILLING ADDRESS FACILITY NAME McDonald's SITE ADDRESS 563 Street Number Direction Carolyn Weston Blvd. Street Name Stockton CA City 95206 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2999 Street Number Oak Road, Suite 900 Street Name CITY STATE oA zIP 94597 Walnut Creek PHONE #1 EXT. ( 650) 350-9471 APN # 164-220-01 LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Drew Sanchez CHECK if BILLING ADDRESS BUSINESS NAME McDonald's USA LLC. P 0 350-9471 (Figi g6 ) EXT. HOME or MAILING ADDRESS 2999 Oak Rd. Suite 900, FAX # ( ) CITY Walnut Creek STATE CA ZIP 94597 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, ST ATE and FEDERAL laws. DATE: 01/16/23 PROPERTY / BUSINESS OWNER'e OPERATOR / MA GER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ic)e ,() 6-r-A c , v t g e (` Al COMMENTS: ill RECEIVE10"E' 'Ap.e..t(- ei,,,,,,c cry, ,&.,t ,,,....p...._ JAN 2 6 2#4 jo4N 30 202 P JOAI '194 t [ENVIRONMENTAL A %-• 0c/A /V7-4 i PERMIT/SERVICES 7104 ACCEPTED BY: -4.4 es Cel EMPLOYEE #: DATE: , i _ ASSIGNED TO: p ,(1.4,a 2...e.„ EMPLOYEE #: DATE: t ---3d , 2...7.7 Date Service Completed (if already completed): SERVICE CODE: 57....) PIE: (6,/ Fee Amount 1.1_(„2--, OLD Amount Paid4 ifroS, O D Payment Date 36 23 Payment Type d_e___. Invoice # Check # ) ,s---g ecei ed APPLICANT'S SIGNATURE: SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003