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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Canteen @Amazon SCK4 <br />SERVICE REQUEST # <br />BUSINESS NAME <br />PHONE # <br />EXT' <br />Compass Group USA Inc dba Canteen <br />skOOS <br />,� <br />OWNER/ OPERATOR <br />FAx # <br />121 <br />( 704) <br />295-5041 <br />CITY Charlotte STATE <br />CHECK It BILLING ADDRESS <br />Compass Group USA Inc <br />dba Canteen <br />FACILITY NAME <br />Canteen @ Amazon SCK4 <br />SITE ADDRESS <br />6001 <br />io <br />I <br />I <br />Austin Road <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <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 />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />Charlotte <br />NC <br />28217 <br />PHONE #1 EXT' <br />APN # <br />LAND USE APPLICATION # <br />1 704) 328-5521 <br />PHONE #2EXT• <br />( ) Nicole.Rollia com <br />ass-usa.com <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Canteen @Amazon SCK4 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />EXT' <br />Compass Group USA Inc dba Canteen <br />1 704 <br />328-5521 <br />HOME or MAILING ADDRESS <br />FAx # <br />Compass Group USA Inc, 2400 Yorkmont Road, Attn: Licensing <br />( 704) <br />295-5041 <br />CITY Charlotte STATE <br />NC <br />ZIP 28217 <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 laws. <br />APPLICANT'S SIGNATURE: In $' I f-+ DATE: 9/10/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />IfAPPL/CANT is not the BILL/NG PARTY proof of authorization to 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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anq at the same time it is <br />provided to me or my representative. • Pd V. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: Vidal Pedraza <br />ASSIGNEDTO: GiglFahmy <br />Date Service Completed (If already completed): <br />Fee Amount: 152 1 Amount Paid <br />Payment Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Invoice # <br />Payment confirmation # 131495842 <br />EMPLOYEE#: 6213 <br />EMPLOYEE#: 8788 <br />Check # <br />SERVICE CODE: 061 <br />Payment Date <br />� <br />S, 14 V <br />?0 <br />INJp 2% <br />v/NiONp RCOU4�T9DEFNTN <br />T yq <br />TME <br />DATE: 9-14-21 <br />DATE: 9-14-21 <br />Q P I E: 1602 <br />eceived By: / <br />SR FORM (Golden Rod) <br />S <br />