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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST ARCO Fac. No.82617/Our Job No.20106 Type of Business or Property FACILITY ID# SERVICE REQUEST# Convenience Store/ Gas Station �=j M-7%a i5 OWNER I OPERATOR CHECK If BILLING ADDRESS❑ Jeskul Enterprise, LLC FACILITY NAME ARCO am m SITE ADDRESS 1100 South Main Street Manteca 95337 Street Number I Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) not grovided to apolicant Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# ( 209 ) 825-6784 221-190-62 PHONE#2 EXT. BOS DISTRICTS\ LOCATION ODE ( ) C 0 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Caitlin Hepworth - Assistant Planner BUSINESS NAME PHONE# ExT. Bar hausen Consulting Engineers, Inc. 425 251-6222 7361 HOME or MAILING ADDRESS FAX# 18215 72nd Avenue South ( 425 ) 251-8782 CITY Kent STATE WA ZIP 98032 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, STATE anq FEDERAL laws. APPLICANT'S SIGNATURE: 1�4l1 DATF: 06/08/2018 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AL THORIZED AGENT❑ If APPLICANT is not the BILLING PART)',proof of authorization to sign is required ily AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the p4�� 9I t the above site address, hereby authorize the release of any and all results, geotechnical data and/or environ) ental/ ment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aAtlp Game time it is provided to me or my representative. SAty� ` 2018 TYPE OF SERVICE REQUESTED: Y'l �olt� (� h��T tRCNMF CSN COMMENTS: RTMFtyi- Installation of an electrical outlet for the new coffee equipment, removal and replacement of coffee equipment, adding a deli case, installing a pre-manufactured air curtain over the front doors of the facility. ACCEPTED BY: EMPLOYEE#: DATE: 4,11111S ASSIGNED TO: G EMPLOYEE#: DATE:/ I t/J Date Service Complete (if air dy completed): SERVICE CODE: tj is P 1 E: (6 L f Fee Amount: 3 -- Amount Pai 36<�,b Payment Date 1�1/ ;/ F Payment Type (?_K_ Invoice# Check# 95 /3 Received By: EHD 0 17/2003 (��J j 0-73 � 0 SR FORM(Golden Rod) REVISED 11 s