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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 <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS❑ <br /> Valley Diner Management, Inc. <br /> FACILITY NAME <br /> Denny's <br /> SITE ADDRESS 4747 Pacific Ave Stockton 94538 <br /> Street Number Direction Street Name City Zip code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3550 Mowry Ave <br /> Street Number Street Name <br /> CITY Fremont STATE CA <br /> zip 94538 <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> ( 510) 792-3393 <br /> PHONE#2 EXT_ BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR William Ross CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT, <br /> Quality Choice Construction ( 702) 641-2400 <br /> HOME Or MAILING ADDRESS FAx# <br /> 2755 S NeIGs Blvd. Suite #10 <br /> ( 702) 641-240 <br /> CITY Las Vegas STATE NV ZIP 89121 <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 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 1 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 /> APPLICANT'S SIGNATURE: � �—) –I1—_ DATE: 6/3/2022 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Representative <br /> If fIPPLILANT 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 Sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE GORE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />