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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # SERVICE REQUEST # <br />ScZCC(D.DSCit <br />OWNER / OPERATOR <br />McDonald's USA, LLC CHECK if BILLING ADDRESS <br />FACILITY NAME <br />McDonald's <br />SITE ADDRESS 2611 <br />Street Number Direction <br />Reynolds Ranch Parkway <br />Street Name <br />Lodi <br />City <br />95240 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2999 <br />Street Number <br />Oak Road <br />Street Name <br />CITY STATE ZIP <br />Walnut Creek CA 94597 <br />PHONE #1 EXT. <br />( 650 ) 350-9471 <br />APN # <br />058-660-18 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Mike Yao myao@core-states.com CHECK if BILLING ADDRESS <br />BUSINESS NAME Core States Group <br />PHONE # <br />( 909) <br />Err. <br />467-8937 <br />HOME or MAILING ADDRESS <br />4240 E Jurupa St. Suite 402 <br />FAX # <br />( ) <br />CITY Ontario STATE CA ZIP 91761 <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 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 la <br />DATE: / <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Kei <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />06/08/2023 <br />Project Manager <br />Title <br />APPLICANT'S SIGNATURE: <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. <br />TYPE OF SERVICE REQUESTED: 14fGO -Pertsd ga1.4-14 <br /> <br />' 1 r. Ic i ll.1 <br />COMMENTS. 1 v <br />F--C>r T F-c, c2D pi,__ANI j°4I 0 8 <br />/-4'w J0,4 <br /> <br /> - 2023 <br />1LvrviR8k-',,1 /4 co, <br />'‘7-111 1117- <br />ACCEPTED BY:EMPLOYEE #: DATE' ,..... c.> -‘...... )._ 3 <br />ASSIGNED TO: Pc <br />EMPLOYEE #: DATE. ____ 8-- ..... .-T3 <br />Date Service Completed (if already completed): SERVICE CODE: ••••3 2...;. PIE: i (DO i <br />Fee Amount: 0-7 0 f)..... , c., 07 Amount Paid O...2. cc) Payment Date C) <br />Payment Type N el ' L rr Invoice # Check # /63 5-1 2_77g Receiveid By: 0 <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003