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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVIcE0 Restaurant - Food Court BUSINESS NAME Rocklin Moo Moo's LP ASSIGNED TO: lO'v OWNER/ OPERATOR Rocklin Moo MOO'S LP CHECK if BILLING ADORES FACILITY NAME MOO Moo's Burger Barn CITY Stockton SITE ADDRESS 3200 Amount Paid Naglee Rd, Suite 608 I Payment Type Tracy 95304 Street Number I 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 En. APN # LAND USE APPLICATION # (209 )957-3989 212-050-35 N/A PHONE #2 Exr. BOS DISTRICT LOCATION CODE (209 ) 607-0834 rnNTR ArTnR / SERVICE, REOUESTOR BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnorized 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, Standards, ST TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08/02/2017 PROPERTY/ BUSINESS OWNEIIZ OPERAT /MANAGER ❑ OTHERAUTHORIZED AGENT ❑ Pres. Managing Partner If APPLICANT is not the BILLING ARTY proof of authorization to sign is required Title 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, 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 TYPE OF SERVICE REQUESTED: Food Service Facility Inspection COMMENTS: This facility is in West Valley Mall's Food Court - Tracy, CA REQUESTOR Nabil Zumout CHECK If BILLING ADDRESS BUSINESS NAME Rocklin Moo Moo's LP ASSIGNED TO: EXT. PHq�(�EIF 957-3989 HOME or MAILING ADDRESS 2800 W March Lane, Suite 340 Date Service Completed (if already completed): FALX # (209 )477-7611 CITY Stockton STATE CA Zip 95219 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnorized 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, Standards, ST TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08/02/2017 PROPERTY/ BUSINESS OWNEIIZ OPERAT /MANAGER ❑ OTHERAUTHORIZED AGENT ❑ Pres. Managing Partner If APPLICANT is not the BILLING ARTY proof of authorization to sign is required Title 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, 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 TYPE OF SERVICE REQUESTED: Food Service Facility Inspection COMMENTS: This facility is in West Valley Mall's Food Court - Tracy, CA ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): I SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003