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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,;SERVICE REQUEST# <br /> KRESTAURANT I` <br /> OWNER/OPERATOR <br /> CHIPOTLE MEXICAN GRILL, INC. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> CHIPOTLE MEXICAN GRILL <br /> SITE ADDRESS 2601 REYNOLDS RANCH PARKWAY, SUITE 140 LODI 95240 <br /> Street Number <br /> Direction <br /> ire o Street Name city Zig)Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO BOX 182566 <br /> Street Number Street Name <br /> CITY COLUMBUS STATE 0H ZIP 43218 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (614 ) 318-2400 058-660-170-000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> BENJAMIN FIEDLER BFIEDLER@FHAARCHITECTS.COM CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> HARLAN R. FAUST,ARCHITECT 402 895-0878 289 <br /> HOME or MAILING ADDRESS FAX# <br /> 14344 Y STREET,SUITE 204 (402 ) 895-9561 <br /> CInOMAHA STATE NE ZIP 68137 <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 /> APPLICANT'S SIGNATURE: '� DATE: 05 JUN 19 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER At?THORIZED AGENT PROJECT MANAGER <br /> If APPLic,4NT is not the BILLLyG 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 stele time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: EXPEDITED RESTAURANT PLAN REVIEW <br /> COMMENTS: <br /> -SAN �5 2419 <br /> 114y ,AQUt <br /> "r, QEpAR��JV <br /> ENT <br /> ACCEPTED BY: ct�crvt e- EMPLOYEE M DATE: <br /> ASSIGNED TO: /�j`�l EMPLOYEE M DATE: r(4 <br /> Date Service Completed (if already completed): SERVICE CODE: S Z PIE: 1 01( <br /> Fee Amount: r Amount Paid , �- Payment Date <br /> Payment Type�� � Invoice# Check# Z Recei ed By: <br /> EHD 48-02-025 � � t� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />