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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 11 FACILITY ID# SERVICE REQUEST# Quick Serve Restaurant(Carl's Jr.) S ko (o S z 3 OWNER/OPERATOR CHECK If BILLING ADDRESS Womar, Inc. FACILITY NAME q Carl's Jr. # SITE ADDRESS 13,35- Street Number rectio Street Name City Zip Code HOME or MAILING ADDRESS (if Different from Site Address) 2 643 Third St. Street Number Street Name CITY Livermore STATE CA ZIP 94550 PHONE#1 Err. APN# LAND USE APPLICATION# ( 925 ) 292-1024 PHONE#2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Greg Swanson CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. Total Pro'eX Corporation 909 873-1088 HOME or MAILING ADDRESS FAx# 1426 S. Willow Ave. ( 909) 873-0802 CITY Rialto STATE CA ZIP 92376 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STA and DERAL laws. APPLICANT'S SIGNATURE: DATE: 7-9-2012 PROPERTY/BUSINESS OWNER❑ PERA R/MANAGER ❑ OTHER AUTHORIZED AGENT® ProiectManag_er /f APPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Final Inspection for New Carl's Jr. Kitchen Equipment for Biscuit Program COMMENTS: New equipment includes (2)stacked ovens,oven timers, a Hatco warming unit to keep the biscuits warm after they are cooked and a prep area made up of stainless steel prep table and a mixing bowl used to mix the dough by hand. ACCEPTED BY: EMPLOYEE#: DATE: 'U l ASSIGNED TO: I J L� EMPLOYEE#: Date Service Completed (if already completed): SERVICE CODE: j P/E: 1 U a Fee Amount: l a S�c� Amount Paid k Z�c' P l� �l�Cpte ( p f Payment Type C/ Invoice# Check# A I4 MED Received By: JUL 10 2012 EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT