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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# i SERVICE REQUEST# <br /> Restaurant FA0014657 Q LL "-�'S�I <br /> OWNER/OPERATOR <br /> Mac Acquisition LLC CHECK If BILLING AOORESS� <br /> F,gc0 NAME <br /> s Macaroni Grill <br /> SITEADDRESS5420 Pacific Avenue Stockton 95207 <br /> Street Number Direcllon Street Nema City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)(mailing) <br /> L2Y000 S Colorado Blvd., Tower 2, Suite 400 Slreat Number Street Name <br /> CI Lenver STATE CO Zip 80222 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 720) 699-0272 AR0024926 <br /> PHONE#2 EUT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REUESTOR <br /> Itailian Restaurant Group LLC CHECK If BILLING ADDRESSE] <br /> S <br /> INESS Nµ PHONE# E.T. <br /> yosmano s�acaroni Grill 7201 699-0272 <br /> HOME or MAILING ADDRESS 'FAX# <br /> 2000 S Colorado Blvd., Tower 2, Suite 400 1 ( ° ) <br /> CITY Denver STATE CO ZIP 80222 <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 die 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: DATE: 10/20/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ®CFO OTHER AUTHORIZED AGENT 1:1 <br /> IfAppucmT is Hot the BILLING)DART proof of aNtlia•izatiorr to sign is regNired T ifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at (he <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the sAle ltme it is <br /> provided to me or my representative. A)/ <br /> TYPE OF SERVICE REQUESTED: Ownership change CFS <br /> COMMENTS: T D <br /> No physical changes.No menu changes. This was solely a reorganization. OCT20 <br /> 20 ? <br /> SANui <br /> JOA QUI <br /> yEA Ty D f q/T7E �Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: �{7 221 <br /> Date Service Completed (if already completed): SERVICECODE: PIE: �o , <br /> Fee Amount: Amount Paid Q Payment Date <br /> Payment Type Ck4d/ Invoice# Check# //�C-/G 2 Received By: <br /> EHD 48-02-025 t' � 1. 3�J SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />