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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busineaa or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant FA 0002757 <br /> OWNER f OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Peoria Paradise P*t LLC <br /> FACIuTY NAME <br /> The RreadWd Tree <br /> SITE ADDRESS mss Rio Blanco Road Stockton ss21s <br /> Street Number Direction Street Name C7t COd° <br /> HoME or MAILING ADDRESS lit Different#ram Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE M EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 952-1000 07112013 <br /> PHONE#2 T- BOSDr57RICT LOCATION CODE <br /> ( } 004 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> IREQUESTOR <br /> GFfECK if r31LUNG AD➢KESS <br /> Howard Weinberg <br /> BUSINESS NAMEPHONE# Eur. <br /> PelQria Paradise Point LLC (zas ) ssza000 <br /> I$OME or MAILING ADDRESS FAX# <br /> 5065 Rio Blanco Road ( 209 } 952-7s74 <br /> CIN Stockton STATE CA ZIP 995219 <br /> 'I''TLTYN(r A�I'N(7WLE'l7fiF,n47: TT:: 1, the undersigned property or business owner, operator or authorized agent of same. <br /> aknowledge that all site and/or project specific ENvIRONMEmTAL l'IEALTII DEPARTmENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forin. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordinee with all SAN JOAQUIN <br /> COUNTY Ordinance Codes.5tanciat-ds TrA'rt and EDERZAI..la <br /> A]�PTP—_A.l:t€''- wFrTTA.TTjrE: t ft�1)aTE: « 1 <br /> PROPER'ry/Busir,'ESS 0ANNERE]01TIZ.TOR/1S(A,IAGER 13 �)3'11F.R r11: OR17.ED riCF.NT❑ <br /> IfAPPLICAVT is not the RIL.LIIVO PARTY,goof of authorization to sign is required Title <br /> AUTHORIZATION TO RE,LFASE INFORMATION: When applicable,1,the owner or operator ofthe property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or eilvironirientaUsitc assessment <br /> infomialion to the SAN JOAQUIN COUNTY l Nl'IRON,Nttuti`TAL I1RAIA-11 DF.PARTMTNT as soon as it is available and at the same time it is <br /> provided to ine or my representative. <br /> TYPE of SERMcE REauESTED: Consultation Inspection <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: EMPLOYEE#: DATE: <br /> Date Service Completer! (if already completed): SERYICPCODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check#r' Received By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />