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DATE: 9/16/2022 <br />PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El <br /> <br />Agent <br />Applicant: Jan Bustalino I Permit Advisors 1(818) 929-1035 I JAN@PERMITADVISORS.COM I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE UEST <br />Type of Business or Property <br />Mercantile Store <br />FACILITY ID # SERVICE REQUEST # <br />SIQ00%914/ <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Five Below Inc. <br />SITE ADDRESS 4950 <br />Street Number Direction <br />Pacific Ave Suite 445 <br />Street Name <br />Stockton <br />City <br />95207 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />102-230-05 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Pedro Baires and Dennis Austria CHECK X if BILLING ADDRESS <br />BUSINESS NAME MCG Architecture PHONE # <br />( ) <br />415 - 974-6002 <br />EXT. <br />HOME or MAILING ADDRESS 250 Sutter St - Suite 450 FAX # <br /> ( ) <br />crry San Francisco STATE CA ZIP 94108 <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 1 have prepared <br />COUNTY Ordinance Codes, Stand <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER El <br />plication a d that the o to be performed will be done in accordance with all SAN Jo/WIN <br />rds, S TE an EDERAL — <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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. PAYMENT <br />TYPE OF SERVICE REQUESTED: Plan check RECEIVED <br />COMMENTS: <br />electronic <br />b aDV) &Y) C ij 0-Y <br />C/OY(t) <br />, <br />( *k-C-i—Wi'e 1 <br />SEP 2 0 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 9-19-22 <br />ASSIGNED To: Lydia Baker EMPLOYEE #: DATE: 9-19-22 <br />Date Service Completed (if already completed): SERVICE CODE: 61 P 1E: 1601 <br />Fee Amount: 468 Amount Paid Payment Date DV 4,1,7 —7 <br />Payment Type (___ L Invoice # Check # Received By: <br />EHD 48-02-025 payment 150010399 SR FORM (Golden Rod) <br />REVISED 11/17/2003