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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 Ll SiR oos Z <br /> OWNER/OPERATOR <br /> Mike Peltekci CHECK if BILLING ADDRESS SLI <br /> FACILITY NAME <br /> Charleys Philly Steaks <br /> SITE ADDRESS W Grant Line Rd95304 <br /> 3010 Tracy <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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rachael Burdon CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> StudioRG 516- 669-4762 <br /> HOME or MAILING ADDRESS FAX# <br /> 1 Huntington Quadrangle Ste 2CO3 ( ) <br /> CITY STATE ZIP <br /> Melville NY 11747 <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: DATE: 08/05/2022 <br /> PROPERTY/BUSINESS OR'NER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT . Expediter <br /> /f iIPPLICANT 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 HEALTI-i DEPARTMENT-as soon as it is availlawle ' .tf same time it is <br /> provided to me or my representative. �t1 �1�j �� <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> (J <br /> COMMENTS: AU6 0 9 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: )3 DATE: Z <br /> ASSIGNED TO: /� EMPLOYEE#: 6 DATE: <br /> Date Service Completed (if already completed): SERVICE DE: P I E: fi�V <br /> Fee Amount: (0 X Amount Paid Payment Date of ZZ V <br /> Payment Type Invoice# Check# Received By: <br /> EHD '�✓��-A., SR FORM(Golden Rod) <br /> REVISED 11/17/2003 PAV <br /> , LQ QL31 <br /> 2 � , -'V Lo 3 �' <br />