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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Q FACILITY ID # BUSINESS NAME C. C. Planning & Permitting Services SERVICE # PHONE# 559 Em 720-8638 HOME or MAILING ADDRESS 3275 N Dante Ave. 2REQUEST Quick Serve Restaurant CITY Fresno STATE CA ZiP93722 U 7 OWNER/ OPERATOR CHECK BILLING ADDRESS El Ghai Management Services. EMPLOYEE#: 6213 If FACILITY NAME EMPLOYEE#: 8788 Popeye's Chicken Date Service Completed (if already Completed): Ir SITE ADDRESS 744 North I Jack Tone Road I 456To Ripon, CA oD 95366 Street Number Direction SVeet Name city ReceivedBy: Zip Co e HOME or MAILING ADDRESS (If Different from Site Address) 25 E. Airway Blvd. Slreet Number Street Name CITY Livermore STATE CA ZIP 94551 PHONE #1 En. APN # LAND USE APPLICATION # ( 510 ) 573-5905 250-250-14 & 15 D19-0012 PHONE #2 El . ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Charlie Brown, Owner Q CHECK If BILLING ADDRESS El BUSINESS NAME C. C. Planning & Permitting Services SAN ?021 PHONE# 559 Em 720-8638 HOME or MAILING ADDRESS 3275 N Dante Ave. FAX # NAR'V7,44 CITY Fresno STATE CA ZiP93722 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 JOAQU IN COUNTY Ordinance Codes, Standards, STAT7TI aws. APPLICANT'S SIGNATURE: DATE: 05/17/2021 PROPERTY/BUSINESS OWNER® OPERATOR/ MANAGER OTHER AUTHORIZED AGENT L1 If APPLlCAN7 is not the BlL6TNGPAR7T proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 enviro tai/site assessment information to the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available�cd��gyTAe time it is provided to me or my representative. /// `C�r t , Y �' TYPE OF SERVICE REQUESTED: Plan review Q COMMENTS: SAN ?021 HEA TyR NAR'V7,44 T ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 5-26-21 ASSIGNEDTO: Gehane Fallmy EMPLOYEE#: 8788 DATE: 5-26-21 Date Service Completed (if already Completed): Ir SERMCE CODE: 523 P I E: 1601 Fee Amount: 456To Amount Pai-' oD Payment Date YL/Op,/ Payment Type Invoice # I Check # /)-SF5 ReceivedBy: EHD 48-02-025 Payment confirmation # 125887234 SR FORM (Golden Rod) REVISED 11/17/2003