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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Food Restaurant Y G �( <br /> OWNER/OPERATOR Hl 0 0 <br /> Chick-fil-A /Operator Micah Payton CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Chick-fil-A (#04047 Hwy 99 & Yosemite Ave) <br /> SITEADDRESS 1405 E Yosemite Ave Manteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 239-2000 20830009 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> (303 ) 945-9247 3 ; <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Amy Hendrickson CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# ExT. <br /> Harrison French & Associates (479 ) 273-7780 194 <br /> HOME or MAILING ADDRESS FAX# <br /> 1705 S Walton Blvd. (888 ) 520-9685 <br /> CITE" Bentonville STATE AR ZIP 72712 <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 /> 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 /> DkjbiN signed by Amy H,nd—n <br /> APPLICANT'S SIGNATURE• Amy HendrlCkSOn Puna EA MatesacN—=A,y Hendnck5�o�o=Hem,on <br /> Dw:2023.06.14 u:oaawsad' DATE: 6/14/2023 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Permit Administrator <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 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: PAYMENT <br /> � RECEIVED <br /> COMMENTS: (� �_ Q � � 1 t o f� `.� JUN 15 2023 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENI <br /> ACCEPTED BY: 31C �,f v���='c EMPLOYEE#: DATE: b ' ^2 / <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: sr2-3 P 1 /! &o <br /> Fee Amount: 4 Amount Paid Payment Date <br /> Payment Type V 65 Invoice# eck# I 3 S?J Received By: <br /> EHD 48-02-025 I L��L7j SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />