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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PLEASE EXPEDITE PLAN CHECK <br /> Type of Business or Property FACILITY ID# SnnERVICE RE WEST# <br /> Pizza 2�,1 �3 sly 66� p <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS ED <br /> Positive Pizza People,Inc.,dba Domino's Pizza <br /> FACILITY NAME <br /> Domino's Pizza <br /> SITE ADDRESS ]s9 95210 <br /> 7908 Suite#2 Stockton c. teas <br /> treet Number Direction West Lane Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3220 Street Number Cathedral Circle Street Name <br /> ClSTATE CA 95212 ZIP 95212 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209 ) 649-2411 68657700°1 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Heidi Miller CHECK If BILLING ADDRESS <br /> Ezr' <br /> BUSINESS NAME PHONE#Acute Consulting 1 925) 818-4132 <br /> HOME Or MAILING ADDRESS FAX# <br /> 29 Orinda Wa #1267 ( > <br /> CITY Orinda STATE CA ZIP 94563 <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 ENviizomoteNTAL 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�IUn 17 ,11, nws. <br /> APPLICANT'S SIGNATURE: V 11I DATE:: 12-15-17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ❑ r <br /> MANAGEROTHER AUTHORIZED AGENT 113 Consultant for Business Owner <br /> IfAPPL/CANT is 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: InterioI TI Plan Check for Pizza Restaurant <br /> COMMENTS: DEC 19 2017 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: .� EMPLOYEE#: DATE: ?A 19 1 t;:� <br /> ASSIGNED TO: r 1_ <br /> EMPLOYEE DATE: I c-1 l <br /> Date Service Completed (i eady completed): SERVICE CODE: X23 P 1 : 6 <br /> Fee Amount: 80 Amount Paid c (Q gL�,LTD Payment Date ("t <br /> Payment Typ Invoiice# Check# Received By <br /> EHD 48-02-025 C �'L '—" AUT SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />