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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST PLEASE EXPEDITE PLAN CHECK Type of Business or Property FACILITY ID # SERVICE REQUEST # Pizza PHONE # ExT. SROD� b-7 L{, OWNER / OPERATOR 925 818-4132 Positive Pizza People, Inc., dba Domino's Pizza CHECK If BILLING ADDRESS FACILITY NAME 29 Orinda Way #1267 Domino's Pizza ( ) SITE ADDRESS 1045 N Wilson Way �� . QO Stockton A 95205 Street Number Direction Payment Type Street Name 'c Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Received By: 3220 Cathedral Circle Street Number Street Name Ci STATESTATE ZIP CA 95212 PHONE #1 Em APN # LAND USE APPLICATION # (209 ) 649-2411 PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Heidi Mller CHECK if BILLING ADDRESS❑ BUSINESS NAME PHONE # ExT. Acute Consulting, Inc. ASSIGNED TO: 925 818-4132 HOME or MAILING ADDRESS EMPLOYEE #: FAx # 29 Orinda Way #1267 ( ) CITY Orinda STATE CA ZIP 94563 BILLING ACKNOWLEDGEMENT: 1, 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, ST ' n E AL ws. APPLICANTS SIGNAURE �� DATE: 2-6-18 PROPERTY/ BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT G Consultant for Business Owner If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 14EALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Interior TI Plan Check for Domino's Pizza Restaurant and adjaceimectema COMMENTS: E-x� r LI% lcc. is /I FEB 14 2018 e.( `e iL -� ` /4A SU b(%4/ SANJOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: w -r t e6 c -v EMPLOYEE #: DATE: .C.. IgI l r V ASSIGNED TO: EMPLOYEE #: DATE: '' 15 �, Date Service Completed (if already completed): SERVICE CODE: 523 PIE: ! Wj Fee Amount: �� . QO Amount Paid 8 t,l Payment Date a / 1,4 / g Payment Type G Ir Invoice # Check # t 3 G( (/ Received By: M EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 vkeo�,��LijkvZ