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New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name CHIPOTLE MEXICAN GRILL <br />City State ZIP <br />CA 95206STOCKTON <br />Supervisor District <br />Repairs or Remodel□ Consultation □ Change of Owner □ Other <br />TENANT IMPROVEMENT FOR NEW CHIPOTLE GOING INTO EMPTY BUILDING (1ST TENANT) <br />License Plate Number VIN <br />□ Facility Contact □ Architect□ Billing Party □ Facility Owner □ Property Owner □ Contractor <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />AO <br />If contractor, indicate type and license number <br />Address State ZIP174 SOUTH ORANGE STREET CA 92866 <br />Phone Email DEE@AOARCHITECTS.COM <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />11/20/2024DATE: <br />XoTHER AUTHORIZED AGENT PROJECT MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />Fee 5 <br />Payment <br />Rev 07/10/2024 <br />□ Check U Received By CayCz f <br />APN <br />164-220-16 <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Date <br />□ Cash <br />Last name <br />BISHARA <br />City <br />ORANGE <br />Phone <br />626-253-7764 <br />Type of Service <br />Requested <br />Comments <br />Site Address <br />743 CAROLYN WESTON BLVD. <br />yf Architect <br />Contact Types <br />required <br />^fsilling Party <br />W Confirmation tt <br />C (3a <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application^nd ti^t Hie work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. v/'y'if /Czy <br />APPLICANT'S SIGNATURE: XA ----- <br />□ OPERATOR/MANAGER <br />Accepted By <br />_______C(^ / Z'vA Q <br />PE <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required toL’W. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereoyL^W^fci <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative./UQl/ <br />First Name <br />DEANNA <br />Assigned To . <br />L, /T Fvi s