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eP_ osu le, nb <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST iV- 0c)-2--1L] S b <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sushi take-out within Safeway Market e �!J U gcJS7(aq <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADORESSO <br /> Advanced Fresh Concept Franchise Corp. <br /> FACILITY NAME <br /> AFC Sushi Q Safeway#55 <br /> SITE ADDRESS South Mountain House Parkway Mountain House 95931 <br /> 19555 Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 19700 Mariner Avenue <br /> Street Number Street Name <br /> Cm SUTE ZIP90503 <br /> Torrance C./i <br /> PHONE#I EaT' APN# LAND USE APPLICATION# <br /> (310 ) 900-9460 <br /> PHONE#2 EaT. BOS DISTRICT LOCATION CODE <br /> (310 ) 604-3200 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Radice/ Loth CHECK If BILLING ADDRESS EZ <br /> BUSINESS NAME PHONE# <br /> AFC Franchise Corp 900-9460 <br /> HOME or MAILING ADDRESS FAx# <br /> 19700 Mariner Avenue ( ) <br /> CITY Torrance STATE CA ZIP 90503 <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 farm. <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 /> APPLICANT'S SIGNATURE: A&a 4d 1061 DATE: 7/20/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 12 Permits cot Licensing Specialist <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT' <br /> COMMENTS: <br /> JUL 2 5 2022 <br /> .I1I I.:IIe I11.'l!IIPI <br /> II fll III 11, <br /> 1'111t11.IL Nl <br /> ACCEPTED BY: =EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� a EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: `S b — Amount Paid ZS1 5 b Payment DateWK Zp LZ <br /> Payment Type Invoice# Check# //1�7 Received By: <br /> EHD D 17/2003 I O 121 !/0 ZZ SR FORM(Golden Rod) <br /> REVISE <br />