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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />`l V <br />FACILITY ID # <br />Canteen @Amazon TCY5 <br />SERVICE REQUEST # <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />Er. <br />Compass Group USA Inc dba Canteen <br />OWNER/ OPERATOR <br />328-5521 <br />HOME or MAILING ADDRESS <br />Compass Group USA Inc dba Canteen <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />( 704) <br />295-5041 <br />Canteen @ Amazon TCY5 <br />NC <br />Zip 28217 <br />SITE ADDRESS <br />DATE: 9-14-21 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 061 <br />P I E: 1602 <br />Fee Amount: <br />6250 <br />Amount Paid /S <br />Payment Date 9 <br />Promontory Parkway <br />. Sd-- <br />Tracy <br />9z3 code <br />StreetNumber <br />Direcaon <br />Street <br />city <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2400 <br />Yorkmont Road <br />Compass Group USA Inc. Attn: Licensing <br />Street Numhar <br />Street Name <br />CITY <br />STATE ZIP <br />Charlotte <br />NC 28217 <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />( 704) 328-5521 <br />PHONE #2EXT. <br />( ) Nicole. Rolli�;(@comr)ass-usa.com <br />ass-usa.com <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />`l V <br />COMMENTS: <br />Canteen @Amazon TCY5 <br />EP 14 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />Er. <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: 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 JOAQUrN <br />COUNTY Ordinance Codes, Standards, STATE andFEDERALlaws. <br />APPLICANT'S SIGNATURE: I/y "" DATE: 9/10/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT [I <br />IfAPPLLcaNT is not the BILLING PAR7Y 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 environmentaVsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avai6ble and at the same time it is <br />1D r.' <br />provided to me or my representative. _)qW Ar, <br />TYPE OF SERVICE REQUESTED: micromarket <br />`l V <br />COMMENTS: <br />EP 14 <br />sAN� 2021 <br />HSE TH pGNMENTVNTy <br />EPgRTMFNT <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 9-14-21 <br />ASSIGNED TO: Kadeanne LHthareS <br />EMPLOYEE#: 4589 <br />DATE: 9-14-21 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 061 <br />P I E: 1602 <br />Fee Amount: <br />152 <br />Amount Paid /S <br />Payment Date 9 <br />Payment Type <br />. Sd-- <br />I Invoice # <br />Check # 131 •JC/S ,? J2 <br />I Receiv d By: <br />EHD 48-02-025 Payment confirmation # 131495842 <br />REVISED 11/17/2003 <br />9 r ;-4,1333 <br />SR FORM (Golden Rod) <br />S <br />