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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 SCK1 <br />SERVICE REQUEST # <br />BUSINESS NAME <br />PHONE # <br />Eu. <br />Compass Group USA Inc dba Canteen <br />704 <br />Ug4 <br />OWNER i OPERATOR <br />FAX # <br />CHECK If BILLING ADDRESS <br />Compass Group USA Inc <br />dba Canteen <br />CITY Charlotte STATE <br />NC <br />FACILITY NAME <br />Canteen @ Amazon SCK1 <br />SITE ADDRESS <br />4532 <br />I <br />Newcastle Road <br />Stockton <br />95215 <br />Street Number <br />Oirectlan <br />SVeet Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2400 <br />Yorkmont <br />Road <br />Compass Group USA Inc. Attn: Licensing <br />Street Number <br />SVeet Name <br />CITY <br />STATE <br />ZIP <br />Charlotte <br />NC <br />28217 <br />PHONE#1 En. <br />APN # <br />LAND USE APPLICATION # <br />( 704q) 328-5521 <br />P14ONE#2Exr. <br />( ) Nicole. Rolli�;(@Comipass-usa.com <br />ass-usa.com <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Canteen @Amazon SCK1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />Eu. <br />Compass Group USA Inc dba Canteen <br />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: 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 />P <br />APPLICANT'S SIGNATURE: /"� y ✓L+— DATE: 9/10/2021 <br />PROPERTV/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />IfAPPLICANT is not the BILLWG PAR TP 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 pmd at the same time it is <br />provided to me or my representative. Pa V. <br />TYPE OF SERVICE REQUESTED: micromarket axCC �ryr <br />COMMENTS:nEP 14 <br />N3FqNgITN0QUIN CARIDP?702% <br />Tll`lfA(7- <br />ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 9-14-21 <br />AssIGNEDTO: Gigl EMPLOYEE#: 8788 DATE: 9-14-21 <br />Date Service Completed (If already completed): SERVICE CODE: 061 P I E: 1602 <br />Fee Amount: 152 Amount Paid Payment Date <br />Payment Type ��_ I Invoice # I Check # Received By:— <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Payment confirmation # 131495842 <br />P064 1321 <br />SR FORM (Golden Rod) <br />s <br />