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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAACCIILITY ID# SERVICE REQUEST# <br /> Fast Food Drive Through Restaurant 2a � ?J� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> In-N-Out Burgers. Inc. <br /> FACILITY NAME T ` <br /> „ — , 1 — 0 I ' <br /> SITE ADDRESS � IV P`-arcific Avenue Stockton 95207 <br /> 5202 Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Hamburger Lane <br /> 13502 Street Number Street Name <br /> CITY STATE ZIP <br /> Baldwin Park CA 91706 P <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (626 )813-8226 102-240-060 P20-0230 Vi-0 <br /> PHONE#2 EaT. BOS DISTRICT LOCAIN O <br /> ( ) SA Z� <br /> CONTRACTOR / SERVICE REQUESTOR HEALTIRoNMECo(/NTY <br /> REQUESTOR r � /e T <br /> CKss t � 7 CHECK If BILLING ADDRESS <br /> ` <br /> BUSINESS NAME i I� 1 J L� w� P NE "� — t�•Z2 <br /> HOME or MAILING ADDRESS 1 �1 lJ> FAX# D <br /> CITY 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 an DERAL laws. <br /> APPLICANT'S SIGNATURRE: �( II� DATE: August 17, 2020 <br /> PROPERTY/BUSINESS OWNER yy OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BLLL/NG PAR 7Y 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Health Department Review <br /> COMMENTS: <br /> In-N-Out is proposing to build a new restaurant at 5202 Pacific Avenue, Stockton, CA 95207 and <br /> requests San Joaquin County County Environmental Health Department review and approval of <br /> our construction drawings in order to obtain our building permits. These drawings are currently <br /> under 1st plan check review by the City of Stockton. G ee- & 2hhDa f r eo /" <br /> ACCEPTED BY: at vvq 6-lti EMPLOYEE#: DATE: —7 C -2- <br /> ASSIGNED TO: f�:71 oh vcC—/(..t EMPLOYEE#: DATE: /—ZC5 <br /> Date Service Completed (if already completed): SERVICE CODE: S PIE: 7 <br /> Fee Amoun . Amount P ' lvg �D Payment Date <br /> Payment Type ` — Invoice# Check# / Z7(, L t) Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />