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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE RE�,I�5T� 1P Roasted Nut Vendor at Stockton Arena c-3 2-c `��?? OWNER/OPERATOR Timothy A. Goree CHECK If BILLING ADDRESS FACILITY NAME Totally Nutz at Stockton Arena SITE ADDRESS 248 WestFremont Street Stockton 95203 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 464 Americano Way Street Number Street Name CITY STATE ZIP Fairfield CA 94533 PHONE#1 EXT• APN# LAND USE APPLICATION# ( 707 ) 410-0494 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( 707) 410-0511 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Timothy A. Goree CHECK if BILLING ADDRESS BUSINESS NAME TKM3 Roasting Company dba Totally Nutz PHONE# ExT. 707 410-0494 HOME or MAILING ADDRESS FAX# 464 Americano Way ( ) CITY Fairfield STATE CA ZIP 94533 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated or activity will be billed to me or my business as identified on this form. //AA'' �VFO 1 also certify that I have prepared this application and that the work to be performed will be done in accordance wwiitthJd[i6 �O�QUIN COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. J o H �W N U1N CO 18 APPLICANT'S SIGNATURE: ,�� DATE: 6/15/2018 �ZTty p� -IJ PROPERTY/BUSINESS OWNER❑ ONAGER R1 OTHER AUTHORIZED AGENT❑ MFjyT If APPLICANT 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Inspection of new food facility Totally Nutz located at Stockton Arena to obtain annual health permit. COMMENTS: We would like to have inspection done between 6/26 and 6/28, if possible. Our secondary choice for inspections would be between 7/10 and 7/13.We have our first schedule event on 7/14. a' t c. �� 1 -$--1CKL a-__, , c I+^ I d I Ile-,( CU"` ACCEPTED BY: , EMPLOYEE#: DATE: /9 / ASSIGNED TO: � O1AV �_ EMPLOYEE#: DATE: (p jCJ x Date Service Completed (if already completed): SERVICE CODE: �� PIE: �G3 Fee Amount: �1j� — Amount Pai �s2 �� Payment Date /o Payment Type W. Invoice# Chk# ? 7� Recei ed By: REVISED 110 17/2003 P� I/ Q t 1 (-1-Cf �'� SR FORM(Golden Rod)