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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Remodel to existing McDonald's Restaurant ]L�A- C003 2 1' o� OWNER i OPERATOR 1 CHECK If BILLING ADDRESS McDonald's USA, LLC Contact person: Matthew Ward FACILITY NAME McDonald's SITE ADDRESS 95376 3430 N Tracy Blvd. TracyT Street Number Direction Street Name Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2999Oak Road Street Number Street Name CITY Walnut Creek STATE CA ZIP 94597 PHONE#1 EXT. APN# LAND USE APPLICATION# ( 916 ) 406-5862 214-210-02 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Matthew Ward CHECK If BILLINGADDRESSE] BUSINESS NAME McDonald's USA, LLC PHONE H NE# EXT. 406-5862 HOME or MAILING ADDRESS FAX# 2999 Oak Road ( ) 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,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �� DATE: 8/12/22 PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ !f 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 availablend at the same time it is provided to me or my representative. ,q TYPE OF SERVICE REQUESTED: Health Department Plan review for remodel to existing McDonald's r COMMENTS: 4 061 electronic SgNJ VU 2 ?0?2 Ew hEA TN p NMFN�UNTV EPq R rMENT ACCEPTED BY: Vidal Pedraza EMPLOYEE M 6213 DATE: 8-12-22 ASSIGNED TO: Kadeanne L1nhares EMPLOYEE#: 4589 DATE: 8-12-22 Date Service Completed (if already completed): SERVICE CODE: 523 P i E: 1601 Fee Amount: 46$ Amount Paid Tlog 0,D Payment Date S� Payment Type d i- Invoice# Check# /Z 927/764 Received By: EHD 48-02-025 paynment 148271760 SR FORM(Golden Rod) REVISED 11/17/2003 n