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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />`.V <br />FACILITY ID # <br />Canteen @Amazon SCK3 <br />SERVICE REQUEST # <br />BUSINESS NAME <br />PHONE # <br />Exr' <br />Compass Group USA Inc dba Canteen <br />1 704 <br />328-5521 <br />OWNER/ OPERATOR <br />FAx # <br />EMPLOYEE#: 6213 <br />Compass Group USA Inc, 2400 Yorkmont Road, Attn: Licensing <br />Compass Group USA Inc <br />dba Canteen <br />C1TY Charlotte STATE <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: 061 <br />P ) E: 1602 <br />Canteen @ Amazon SCK3 <br />Amount Pai <br />Payment Date 7q2/ <br />SITE ADDRESS <br />Invoice# <br />Check# 3 5j9S8gZ <br />I Received By: <br />3565 <br />Airport Wad <br />Manteca <br />95336 <br />Street Number <br />Direction <br />atree[ ame <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2400 <br />Yorkmont Road <br />Compass Group USA Inc. Attn: Licensing <br />SVeet Number <br />Street <br />Name <br />CITY <br />STATE <br />ZIP <br />Charlotte <br />NC <br />28217 <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION <br /># <br />( 704) 328-5521 <br />PHONE #2EZT. <br />( I, Nicole. Rolli�;(@compass-usa.com <br />ass-usa.com <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />`.V <br />COMMENTS: <br />Canteen @Amazon SCK3 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />Exr' <br />Compass Group USA Inc dba Canteen <br />1 704 <br />328-5521 <br />HOME Or MAILING ADDRESS <br />FAx # <br />EMPLOYEE#: 6213 <br />Compass Group USA Inc, 2400 Yorkmont Road, Attn: Licensing <br />( 704) <br />295-5041 <br />C1TY Charlotte STATE <br />NC <br />ZIP 28217 <br />BILLING ACKNOWLEDGEMENT: 1, 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 laws. <br />APPLICANT'S SIGNATURE: I" P ✓t <br />DATE: 9/10/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />I, fAPPLICANT is not the BiLLMG pARTY proof of authorization to sign is required <br />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 availablejtd�at the same time it is <br />provided to me or my representative. F'^I / <br />TYPE OF SERVICE REQUESTED: micromarket <br />`.V <br />COMMENTS: <br />SA iV <br />eAiply <br />HE H') <br />pMERTry/N A'it' <br />FNT <br />ACCEPTED BY: Vida) Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 9-14-21 <br />ASSIGNEDTO: Gigi Fahmy <br />EMPLOYEE#: 8788 <br />DATE: 9-14-21 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 061 <br />P ) E: 1602 <br />Fee Amount: 152 <br />Amount Pai <br />Payment Date 7q2/ <br />Payment Type ! <br />Invoice# <br />Check# 3 5j9S8gZ <br />I Received By: <br />EHD 48-02-025 Payment confirmation # 131495842 <br />REVISED 11/17/2003 <br />P9_13"133° <br />SR FORM (Golden Rod) <br />4 <br />