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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Quick Serve Restaurant <br />FACILITY ID # <br />.9fONS <br />OWNER <br />SERVICE REQUEST # <br />/ OPERATOR <br />CHECK if Quickserve Cajun, Inc. <br />BILLING ADDRESS X <br />FACILITY NAME <br />Popeyes Restaurant <br />SITE ADDRESS 201 <br />Street Number <br />W <br />Direction <br />Charter Way <br />Street Name <br />Stockton, CA <br />City <br />95206 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 25 <br />Street Number <br />E. Airway Blvd. <br />Street Name <br />Orr Livermore STATE CA ZIP 94551 <br />PHONE #1 EXT. <br />( 510 )573-5905 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Charlie Brown, Owner CHECK if BILLING ADDRESS <br />BUSINESS NAME C. C. Planning & Permitting Services PHONE # <br />( 559 <br />Err. <br />) 720-8638 <br />HOME or MAILING ADDRESS 3275 N Dante Ave. FAX # <br />( ) <br />CITY Fresno STATE CA ZIP93722 <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, ST ATE aØ d aws. <br />APPLICANT'S SIGNATURE: DATE: 9/12/2022 <br /> <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at time it is <br />provided to me or my representative. --.... <br />TYPE OF SERVICE REQUESTED: 1„) t `A.) -67-u-A frA.4:t ( <br />COMMENTS: <br />ejaka` <br />OCT 116 <br />2022 SAN Jo A <br />,.., ENvii?OuiN co, . zA LTH come.NTA pry <br />LPA R7-4,7 ,-NT <br />ACCEPTED BY: CR./A& es ,-,3 EMPLOYEE #: DATE: i 0 -6' .-- 1.- 7_ <br />ASSIGNED TO: &t.).1,4,---- EMPLOYEE #: DATE: 1 0 <br />Date Service Completed (if already completed): SERVICE CODE: -I, 3 PIE: two ( <br />Fee Amount: it Ley- ...— Amount Paid ye,E. on Payment Date <br />Payment Type Vi5 Invoice # Check # /Si O24-5-7 -7 Received By:diPtir— <br />EA/ <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003 PR2.50o2pt