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San Joaquin County Environmental Health Department <br />Type of Business or Property <br />Restaurant <br />Manteca <br />Direction City <br />Progress <br />Street Number <br />StateCityIrvine CA 92618 <br />Ext.Land Use Application # <br />640-8833 <br />Ext.Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext. <br />Inc. <br />) <br />State Zip 92506CityRiverside <br />7/27/2023APPLICANT’S SIGNATURE: <br />Title <br />CA <br />Comments: <br />JUL 3 1 2023 <br />Employee#:Accepted By: <br />Employee#:Assigned to: <br />Amount PaidFee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 2-2, <br />Phone #1 <br />(951) <br />SWC Airport Rd & Hwy 120 <br />Street Name <br />APN # <br />24132044 <br />Phone#2 <br />( ) <br />SERVICE REQUEST# <br />95336 <br />Zip Code <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />7^4? <br />_____________________Street Number <br />Home or Mailing Address (If Different from Site Address) 1 q 5 <br />Kelsey Wu <br />Business Name <br />SERVICE REQUEST <br />FACILITY ID # <br />Street Name <br />ZIP <br />CUP 22-108 <br />BOS District <br />Phone# <br />(951) 640-8833 <br />Fax# <br />( <br />CA <br />Date: <br />Property / Business Owner Operator / Manager Other Authorized Agent S21 <br />If Applicant is not the Billing PARTY, proof of authorization to sign is required <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. <br />Type of Service Requested: Plan check for new Chick-fil-A restaurant in Manteca, <br />PAYMENT <br />RECEIVED <br />5^-3 <br />Payment Date <br />Date Service Completed (ir already completed): <br />Payment Type \f[C <br />Check if Billing Address O <br />SAN JOAQUIN COUNTY <br />environmental <br />HEALTH OEPARlMENr <br />Check if Billing Address Ei/l <br />Service Code: <br />pneck# <br />4G Development & Consulting, <br />Home or Mailing Address <br />5535 Intervale Dr <br />Owner / Operator <br />Chick-fil-A <br />Facility Name <br />Chick-fil-A <br />Site Address <br />Date: ? <br />Date: 3 <br />/17 (c^t <br />(T'd I''?’ <br />Received By: