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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S,eoo& 9�3 <br /> Restaurant <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS® <br /> Chipotle Mexican Grill <br /> FACILITY NAME Chipotle Mexican Grill <br /> SITE ADDRESS Stockton 95219 <br /> 10710-AStreet Number Direction <br /> Trinity Parkway Street Name CI zi Coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> APN# LAND USE APPLICATION# <br /> PHONE#1 TBD (When Built) 086-020-019 <br /> PHONIER Erzr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Brett Gray-Agent CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> John Dungan Architects 913 341-2466 <br /> HOME or MAILING ADDRESS FAX# <br /> 8826 Santa Fe Drive, Suite 304 (913 )341-2455 <br /> CITY Overland Park STATE KS LP 66121 <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 FF jT) R�AAT lawc <br /> APPLICANT'S SIGNATURE: DATE: 04/15/14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect/Agent <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 COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 7 <br /> TYPE OF SERVICE REQUESTED: C! / <br /> COMMENTS: APR 15 2014 <br /> ) SAN JOAQUIN COUNTY <br /> CXR ENVIROMENTAL <br /> HEALTH CIFeAHTMENT <br /> ACCEPTED BY: ca EMPLOYEE M a <br /> ASSIGNEDTO: ae5`maoEMPLOYEEM Date Service Completed (if already completed): SERVICE CODE: -Z3Fee Amount: 3'�S Amount Paid3 Payment DatePayment Type V/ Invoice# Check# O� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />