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Type of Business or Property <br />Restaurant with drive thru <br />Check if Billing Address <br />95207 <br />Direction Zip Code <br />Street Number <br />91791 <br />Location CodeExt. <br />418 6474 <br />Requestor <br />Nina Raey <br />Business Name Ext.RSI Group, LLC <br />ZipState 92626CA <br />APPLICANT’S SIGNATURE: <br />Employee #:Date:Accepted By: <br />Employee #:Date:Assigned to: <br />Service Code:/L>0/ <br />Payment DateFee Amount: <br />I7307S070Invoice # <br />EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />I 2-2- <br />Ext. <br />4011 <br />SERVICE REQUEST# <br />SR(Z)0S7505 <br />SR FORM (Golden Rod) <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 or activity <br />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 />City <br />West Covina, <br />Phone #1 <br />(626 ) 369 7718 <br />Phone#2 <br />(626) <br />Type of Service Requested: Food plan check for a new restaurant <br />Comments: AET y-CdZ-Vvo"yftc <br />Owner / Operator <br />Honeybee Food Corps dba Jollibee <br />Facility Name <br />Jollibee Restaurant <br />Site Address <br />4704_____________Street Number <br />Home or Mailing Address (if Different from site Address) <br />100 <br />Stockton, CA <br />City <br />N. Barranca Street, Suite 1200 <br />Street Name <br />Zip <br />Land Use Application # <br />P22-0645 <br />BOS District <br />APN# <br />102-230-17 <br />Email <br />johnny.francisco@jollibeeusa.com_______ <br />CONTRACTOR / SERVICE REQUESTOR <br />___________ <br />Payment Type <br />Amount Paid<^ <br />Check# <br />Phone# <br />(714)227 5223 <br />Fax# <br />( )_________________ <br />Email nina@rsi-group.com <br />Check if Billing AddressLl <br />Home or Mailing ADDRESS <br />3199 Airport Loop Drive, Suite D <br />City Costa Mesa <br />Stateca <br />______________ Date: 12/6/2023 <br />Property/ Business Owner O Operator/ Manager O Other Authorized Agent Q Ager|t f°r Jollibee <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 above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmery^nformation to the <br />San Joaquin County Environmental Health Department as soon as it is available and at the same time it is or my <br />representative. <br />^ent <br />Pacific Avenue <br />Street Name <br />I <br />\Z-^- -L3 <br />P/E: <br />Received By: <br />Date Service Completed (if already completed):