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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Restaurant- Food Court ACCEPTED BY:� I EMPLOYEE #: 7-3989 E> OWNER/ OPERATOR Rocklin Moo Moo's LP EMPLOYEE #: FA"# (209 ) 477-7611 CHECK If BILLING ADDRES FACILITY NAME Moo Moo's Burger Barn ZIP 95219 SITE ADDRESS 3200 Amount Pai r740, Ov Naglee Rd, Suite 608 Payment Type Tracy 95304 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2800 W March Lane, Suite 340 Street Number Street Name CITY Stockton STATE CA ZIP 95219 PHONE #1 EXT. 1209 )957-3989 APN # 212-050-35 LAND USE APPLICATION # N/A PHONE #2 Eu. (209 ) 607-0834 BOS DISTINCT �G LOCATION CODE j CONTRACTOR / SERVICE REOUESTOR REQUESTOR Nabil Zumout CHECK If BILLING ADDRESS BUSINESS NAME Rocklin Moo Moo's LP ACCEPTED BY:� I EMPLOYEE #: 7-3989 E> HOME or MAILING ADDRESS 2800 W March Lane, Suite 340 EMPLOYEE #: FA"# (209 ) 477-7611 c7 Stockton STATE CA ZIP 95219 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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, Stand7'A,'R FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08/02/2017 PROPERTY/BUSINESS OWNEHZ /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Pres. Managing Partner I,fAPPLICANT is not the ATP proof OjauthariZat[on to sign is required Tire AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnicaldata and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA as sos available and at the same time it is provided to me or my representative. p - f /y r PA TYPE OF SERVICE REQUESTED: Food Service Facility Inspection j FC�N % COMMENTS:0 8 This facility is in West Valley Mall's Food Court - Tracy, CA Au''�'ou Aft? HE,V' N/ OM r4 coU I%Y oePM�t ACCEPTED BY:� I EMPLOYEE #: DATE: `(/✓�i� ,: o ASSIGNED TO: I EMPLOYEE #: DATE: � , 3—/ Date Service Completed (if already completed): SERVICE CODE: -L �� P 1 E: / Fee Amount:J�" Amount Pai r740, Ov Payment Date g Payment Type ;6-11 I Invoice # I Ch�dk # -F/9/1 Receiv 9 ci: EHD SED 11/1 l �-t_rr, " � / SR FORM (Golden Rod) REVISED 11/17/2003