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S SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # PHONE # En. Frrla,�J- 1 704 328-5521 'SLMa2 FAX # OWN/ OPERATOR ( 704) 295-5041 CITY Charlotte STATE NC ZIP 28217 CHECK if BILLING ADDRESS Compass Group USA Inc dba Canteen FACILITY NAME Canteen @ Amazon SCK9 ACCEPTED BY: EMPLOYEE #: kA j Gr SITE ADDRESS 4601 I Newcastle Road DATE: 1 1 � Q)Z Stockton 95215 SetNu. Direction Street Name Amount Paid city Zip Code HOME or MAILINGADDRESS (If Different from Site Address) 2400 Yorkmont Road Invoice # Compass Group USA Inc. Attn: Licensing Street Number S' / Street Name CITY STATE ZIP Charlotte NC 28217 PHONE #1 EX . APN # LAND USE APPLICATION # ( 704) 328-5521 PHONE #2T ( ) Nicole. Rollins com ass-usa.com BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # En. Compass Group USA Inc dba Canteen 1 704 328-5521 HOME Or MAILING ADDRESS FAX # Compass Group USA Inc, 2400 Yorkmont Road ( 704) 295-5041 CITY Charlotte STATE NC ZIP 28217 BILLING ACKNOWLEDGEMENT: I, 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: I" P A4 - DATE: 11/18/2021 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ 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/Fij�mggl*, information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th s ��Mssll provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: micromarket NOV 1 8-A COMMENTS: SAN JOAQUIN COU ENVIRONMENT HEALTH DEPARTM ACCEPTED BY: EMPLOYEE #: kA j Gr DATE: I 1 _, 118— Z 1 ASSIGNED TO: EMPLOYEE #: —1 S g I DATE: 1 1 � Q)Z Date Service Completed (if already completed): SERVICE CODE: Ob PIE: Ibo2 Fee Amount: `S2— Amount Paid S2_ Payment Date Payment Type Invoice # J]eek # S' / Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 Pf® 3 VTY NT