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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST" # PHONE # Exr. 3 7 Ss S(2tQ9s°1 Limited Service Resturant FAX # 10525 VISTA SORRENTO PKWY STE. 310 ( ) OWNER /OPERATOR CHECK If BILLING ADDRESS❑ Avery Foods LLC /JOSH FELDMAN FACILITY NAME Jersey Mike's Subs 1 E: SITE ADDRESS Fee Amount: ( Srb Amount Paid I Payment Date -V -,-7L,2, 2982 Invoice # j� GRANT LINESrr pr,,..e Received By: TRACY 9w¢4a Street Number Direction cit HOME or MAILING ADDRESS (If Different from Site Address) 10525 VISTA SORRENTO PARKWAY STE 310 Street Number Street Name CITY STATE ZIP SAN DIEGO CA 92121 PHONE#1 EXT. APN # LAND USE APPLICATION # (858 )337-2020 PHONE#2 En. BOB DISTRICT LOCATION CODE (858 ) 263-1771 11 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS ims OPCO LP BUSINESS NAME PHONE # Exr. JMS OPCO LP EMPLOYEE #: HOME or MAILING ADDRESS FAX # 10525 VISTA SORRENTO PKWY STE. 310 ( ) CITY STATE CA ZIP SAN DIEGO 92121 BILLING ACKNOWLEDGEMENT: I, 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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08/31/2022 PROPERTY/ BOSINEss OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator19A%perty located at the above site address, hereby authorize the release of any and all results, geotechnical data and/orl leUsite assessment information to the SAN JOAQUIN COUNTY. ENvLRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. SEP U 7 2022 TYPE OF SERVICE REQUESTED: change of Owner site Inspection SAN JOAQUIN COUNTY LCNT COMMENTS: HEALTHOE Avery Foods LLC is selling the business to JMS OPCO LP and requires a change in ownership inspection to transfer permit site ACCEPTED BY: %T a fit-�A gI EMPLOYEE #: DATE: ASSIGNED TO: L— , [Acx--e S EMPLOYEE #: I DATE: /'f --7 _ ZL Date Service Completed (if already completed): SERVICE CODE: D 60 / 1 E: &O 2�- Fee Amount: ( Srb Amount Paid I Payment Date -V -,-7L,2, Payment Type C CAI Invoice # C # y I 4t 5'1 Og Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 G