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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c SERVICE REQUEST# <br /> SRestaurant EGI <br /> OWNER I OPERATOR <br /> Raising Cane's Restaurants, LLC - Melanie Bagley CHECK If BILLING ADDRESS❑ <br /> FAauTYNAME Raising Cane's <br /> SITEADDRESS 1311 E I Yosemite Ave. Manteca 95366 <br /> Street Number Directiontreet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6800 Bishop Road <br /> Street Number Street Name <br /> CITY Plano, TX 75024 STATE Zip <br /> PHONE#1 972-369-8409 Ext 499 573-01 LAND use AppucArloNn <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TJ Suwanswetr (Applicant/Auth Agent) <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Permit Place, Inc. I 1 818-573-2483 <br /> HOME or MAILING ADDRESS 13400 Riverside Drive Suite 202 FAX# <br /> CITY Sherman Oaks, CA 91423 STATE zip <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 1 ws. <br /> APPLICANT'S SIGNATURE: ; ✓1 �/,.�^ DATE: 08/20/20 <br /> PROPERTY/BUSINESS OWNER❑ OPERA? R/MANAGER ❑ OTHER AUTHORIZED AGENT IN project Manager <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization 10 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ane same time it i5 <br /> provided to me or my representative. '`I�c <br /> TYPE OF SERVICE REQUESTED: Plan check C, <br /> COMMENTS: <br /> SqN✓ ?$ <br /> h�ACT"0E qRT°��r <br /> MENT <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE. 8-25-20 <br /> ASSIGNED TO: Gehane Fahmy EMPLOYEE#: 8788 DATE: 8-25-20 <br /> Date Service Completed (If already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Paid/ �v Payment Date <br /> Payment Type - Invoice# Check# 81Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />