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P �_ 0 z� czs SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST FACILITY ID# SERVICE REQUEST# Type of Business or Property Sushi take-out TIN OO\ ��o�2. ��W 9� l OWNER/OPERATOR Advanced Fresh Concepts Franchise Corp CHECK if BILLING ADDRESS❑ FACILITY NAME AFC Sushi @ Safeway#2600 SITE ADDRESS 1801 West 11th Street CA 95376 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 19700 Mariner Avenue Street Number Street Name CITY STATE ZIP Torrance CA 90503 PHONE#1 EXT' APN# LAND USE APPLICATION# (310 )900-9460 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Radice/ Loth CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Advanced Fresh Concepts Franchise Corp 310 1 900-9460 HOME or MAILING ADDRESS FAX# 19700 Mariner Avenue (310 )604-6449 CITY Torrace STATE CA ZIP 90503 BILLING ACKNOWLEDGEMENT: 1, 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. 1 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 laws. APPLICANT'S SIGNATURE: �.�e DATE: 7/06/2023 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT® Permits&Licensing Supervisor IfAPPLICANT 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 HEAL"m DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: R COMMENTS: JUL 1 consultation 0 B23 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: Vidal Pedraza EMPLOYEE M 6213 DATE: 7-6-23 ASSIGNED TO: Kadeanne Linhares EMPLOYEE#: 4589 DATE: 7-6-23 Date Service Completed (if already completed): SERVICE CODE: 61 PIE- 1602 Fee Amount: 162 Amount Paid a — Payment Date 10 2,p L 2 Payment Type V 5 Invoice# Check# Received By: 11 EHD 48-02-025 payment 164992722 /�23 SR FORM(Golden Rod) REVISED 11/17/2003 1/ �-