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SAN JOAQUIN _JUNTY ENVIRONMENTAL HEALTH D... ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Quick Serve Restaurant X6 !1 �� b()7u �,1�)--7 <br /> O ER/OPE TOR <br /> eanna ecker/ McDonald's USA LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME McDonald's #004-4307 <br /> $ITE2D8D2EOSS S Tracy Blvd. Tracy <br /> Street Number Direction Street Name c,t, <br /> Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Oak Road <br /> 2999 Street Number Street Name <br /> CITY Walnut Creek STATE CA zip 95497 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 281-9721 :,2 Or 6, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Robert Picard / Stantec Architecture Inc. <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME an ec Architecture Inc. PHONE# EXT. <br /> 7 7 774-9721 <br /> HOME or MAILING ADDRESS FAX# <br /> 1383 N. Mcdowell Blvd. Ste 250 ( ) <br /> CITY Petaluma STATE CA zip 94954 <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 /> 1 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,Stan ,STAT and FEDE L laws. <br /> 1250 APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWN1!i(s' <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPL/C.4 not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS: <br /> JAN 2 5 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: <br /> Date Service Cohn--pleted (if al ady completed): SERVICE CODE: Z J PIE: <br /> Fee Amount: c� Amount Paid tl S Payment Date a <br /> Payment Type G G— Invoice# Check# S S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />