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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant with Drive Thru 9 <br /> 2 <br /> OWNER/OPERATOR TBD CHECK If BILLING ADDRESSO <br /> FACILITYNAME Chick-fil-A <br /> SITE ADDRESS 1405 1 E Yosemite Avenue Manteca 95336 <br /> Street Number 1 Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (it Different from Site Address) 311 N. Citrus Avenue <br /> Street Number Street Name <br /> SJA.TCITY Vista CA ZIP 92084 <br /> PHONE#f EXT. T72U� 8-300-009 <br /> N# LAND <br /> USE APPLJCATioN# <br /> (760) 639.6791 <br /> PHONE#2 EXT. BOS DISRICT_.--_ [LOCATION CODE <br /> ( ) ` f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Brett Keller <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> 76C <br /> 4G Development & Consulting, Inc. 639.8791 <br /> HOME or MAILING ADDRESS FAX# <br /> 311 N. Citrus Avenue ( ) <br /> CITY Vista STATE CA ZIP 92084 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> J also certify that J have prepared this application and that the work to be performed will be done in accordance with alJ SAN JDADIAN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �- �� '-% DATE: 3j- <br /> — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, /goof 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me or <br /> my representative. � Y <br /> TYPE OF SERVICE REQUESTED: plan Check Review ° EC'Pl <br /> COMMENTS: 7 _ % `� -( l7 ' 1S AH 1 MCi in :> >:��-Cit ✓'� � (LC'�liBYt i ,-�, 201 <br /> SAN JOAQUIN COON y <br /> ENVIRONMENTALI JEALTH DEpARTNEN <br /> ACCEPTED BY: 211c.y�( EMPLOYEE#: DATE: <br /> � �I�S c=�> <br /> ASSIGNED TO: SCa VBG �c2 .�C EMPLOYEE#: DATE: -t f <br /> Date Service Completed (if already completed): SERVICE CODE: j 2- PIE: <br /> (!C <br /> Fee Amount: --1 S-�-,. - - Amount Paid ��L�C Payment Date <br /> Payment Type I Invoice# Check# Received By: <br /> ✓�A �(P(P�Ju;✓G <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />