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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Commercial - Restaurant I' HOME or MAILING ADDRESS 637 Fifth Ave., (Q�Z Q Og L, 22. OWNER / OPERATOR CITY San Rafael ® PRB Management, LLC CHECK N BILUNG ADORE FACIuw NAME EMPLOYEE #: Taco Bell Restaurant l -1 1 ASSIGNED TO: C 'fir SITE ADDRESS 421 E. I Yosemite Avenue Date Service Completed (N already completed): Manteca 95337 S1110tNumber Dimfim Amount Pai `J� OD svent N.M. Payment Type city Zop COO HOME or MAILING ADDRESS (It DNforent from Site Address) 4709 Mangels Blvd. Street Number Steet Name Cm Fairfield STATE CA ZIP 94534 PHONE #t E"T APN # LAND USE APPLICATION If (707 )864-2919 PHONE #2 EXT. BOS DISTMCT LOCATION CODE PERMIT CONTACT CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Damien Hannigan, Architect/ Contact CHECK If BILUNG ADORESS13 BUSINESS NAME VMI Architecture Inc. D 1415 451-2500 Ext 124 HOME or MAILING ADDRESS 637 Fifth Ave., E -P 16 2021 FAx# ( ) CITY San Rafael STATE CA Z'P 94901 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEAL'T'H 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 law APPLICANT'S SIGNATURE:DATE: - PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER Iy�( OTHER AuTHORizEn AGENT lfAPPLICANT is not the!BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: FOR HEALTH REVIEW OF PLANS FOR MINOR REMODEL L COMMENTS: D E -P 16 2021 SAN QUINE I1EgLTfRp PITq� TY ACCEPTED BY: W EMPLOYEE #: DATE: l -1 1 ASSIGNED TO: C 'fir EMPLOYEE M DATE: Date Service Completed (N already completed): SERVICE CODE: I C% y , P I E: I Fee Amount,- _ _ Amount Pai `J� OD Payment Date Payment Type Invoice # Check # `v �7 D R cei By: EHD 4"2-025 SR FORM (Golden Rod) REVISED 11/17/2003