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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Fast Food Restaurant Flk. <br />FACILITY ID # <br />000 2--0 i ( <br />SERVICE REQUEST # <br />SR00 V79 34 <br />OWNER! OPERATOR <br />Chick-Ill-A /Operator: April Farage CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Chick-fl-A (#03664 March Lane at 1-5 FSU) <br />SITE ADDRESS 2628 <br />Street Number <br />W <br />Direction <br />March Ln <br />Street Name <br />Stockton <br />City <br />95207 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry. STATE ZIP <br />PHONE #1 Err. <br />(209 ) 477-5936 <br />APN # <br />110-020-040-000 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Amy Hendrickson CHECK if BILLING ADDRESS X <br />BUSINESS NAME HFA-AE, LTD. <br />PHONE # <br />(479 ) <br />EXT. <br />273-7780 194 <br />HOME or MAILING ADDRESS <br />1705 S Walton Blvd. <br />FAX # <br />(888 ) 520-9685 <br />CITY Bentonville STATE AR zw 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 />APPLICANT'S SIGNATURE: Amy Hendrickso Er Vgned by Amy Hendnckson <br />E-arny.hendeckson@hkae.mco, 0-Hanson <br />artd Assookes. UN-Pony Hendnckson <br />2024.04.09 15-57:19-050X DATE: 4/9/2024 <br />PROPERTY / BUSINESS OWNERD OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT NI 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: .-e vtiPJ d PAYMENT <br />RECEIVED <br />COMMENTS: <br />otmA . YeA(2-1CCnI,11) f71 -61b , Mr <br />0 <br />APR 1 5 2024 <br />SAN JOAOUIN COUNTY <br />ENVIRONPIENTAI- <br />REALM DEPARTMENT <br />ACCEPTED BY: C a r (10( CC:N C- <br />EMPLOYEE #: DATE: <br />4'Nk i — .2.-1 <br />ASSIGNED TO: EMPLOYEE #: DATE: d. <br />— II '-- 2-'1 <br />Date Service Completed (if already completed): SERVICE CODE: 6 3 P / E• I (0 0 1 <br />Fee Amount:Amount Paid Payment Date <br />Payment Type \j/5 fr invoice # 914.1159 / <br /> <br />/ / <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />4/i/ 241 V SR FORM (Golden Rod) <br />r -4-- 1-31 (.,0q PkoNDLITI