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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T <br /> RESTAURANCoo-2(-149? �� Ub—)7-7(7 t) <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS[] <br /> AMIR SAHEBALZAMANY <br /> FACILITY NAME <br /> BURGER KING#10368 <br /> SITE ADDRESS 4881 STATE ROUTE 99 STOCKTON 95215 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2821 CROW CANYON ROAD <br /> Street Numher Street Name <br /> CITY STATE ZIP <br /> SAN RAMON CA 94583 <br /> PHONE#i EXT. ApI�# LAND USE APPLICATION# <br /> ( 925)989-1195 179-260-53 <br /> PHONE#2 ExT• BOS DISTRICT�`` LOCATION CODE <br /> C)/ <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTORJOHNDODSON <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> ADNA 310 452-5533 X204 <br /> HOME Or MAILING ADDRESS 1330 OLYMPIC BLVD FAX <br /> ( ) <br /> CITY SANTA MONICA STATE CA ZIP 90404 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 laws. <br /> APPLICANT'S SIGNATURE: DAT-E: 6-21-17 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT■ ARCHITECT <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 JOAQU N 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: r,Z 1'Jarl C1Le- PA�'M <br /> COMMENTS: ' rTtt:CE1V !] <br /> JUN 2 2 20 <br /> N ��o.ti ecoU'rrr <br /> CALT74D&AtRrM kt <br /> ACCEPTED BY: EMPLOYEE#: DATE: • <br /> ASSIGNED TO: EMPLOYEE#: DATE: `7 <br /> Date Service Completed f already completed): SERVICECODE: P!E: <br /> Fee Amount: Amount PaIA0 �'��.Q Payment Date <br /> Payment Type (7p Invoice# Check# 113 7t� Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />