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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Restaurant BUSINESS NAME 9i NW3�:)' OWNER / OPERATOR The Habit Restaurants, LLC � 4 The Habit Restaurants, LLC HOME Or MAILING ADDRESS CHECK NBILLING ADDRESS FACILITY NAME The Habit Burger Grill 17320 Red Hill, Suite 140 DATE: SITEADDRESS 1323 I E. Yosemite Ave #250 I DATE: /Q .00 - 1-7 Manteca 95337 Street Number Direction Fee Amount: 4Amount Street Name -'Ncv O CRY Zip Code HOME or MAILING ADDRESS (if Different from Site Address) 17320 Red Hill Ave #140 Recei d By: Street Number Street Name CITY Irvine STATE CA ZIP 92614 PHONE #I Etn' APN # LAND USE APPLICATION # ( 949 1 851-8881 6-6 (V02� PHONE#2 EXT. SOS DISTRICT LOCATION ODE ( ) 06 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Garrett Baird CHECK If BILLING ADDRESS BUSINESS NAME PHONE # ExT' The Habit Restaurants, LLC � 4 1 9491 943-8643 HOME Or MAILING ADDRESS ACCEPTED BY: FAx # 17320 Red Hill, Suite 140 DATE: ( ) CITY Irvine STATE CA ZIP 92614 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and the the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S L laws. APPLICANT'S SIGNATURE: DATE: 10/27/17 PROPERTY/BUSINESS OWNER 13 O R/MANAGER® OTHER AUTHORIZED AGENT [3 Development Project Manager 1f APPLICANT is not the BILLING PAKTy. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper[ Located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUMsment information to the SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at provided to me or my representative. Lull& Z TYPE OF SERVICE REQUESTED: C% COMMENTS: HE CN�I 'QUI N COON ry TNDEPq� � 4 ACCEPTED BY: =EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: /Q .00 - 1-7 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: 4Amount Pai -'Ncv O Payment Date Payment Type Invoice # Check # '773 Recei d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003