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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # <br />i-- Pc o()‘-g-LtcA <br />SERVICE REQUEST # <br />Si2cop-109 <br />OWNER! OPERATOR <br />BJ's Restaurant Brewhouse CHECK if BILLING ADDRESS and <br />FACILITY NAME BJ's Restaurant and Brewhouse <br />SITE ADDRESS 2770 <br />Street Number Direction <br />Nag lee road <br />Street Name <br />Tracy, CA <br />City <br />95304 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7755 Street Number <br />Center Ave Suite # 300 <br />Street Name <br />CITY STATE ZIP <br />Huntington Beach, CA 92647 <br />PHONE #1 Exr. <br />( 530 ) 556-9616 <br />APN# 21,205,060 LAND USE APPLICATION # <br />D23-0005 <br />PHONE #2 ExT. <br />( ) <br />EMAIL <br />Jeremy@goldenpd.com <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BJ's Restaurant, Inc C/O GPD, LLC Attn: Jeremy Layton CHECK if BILLING ADDRESS <br />BUSINESS NAME BJ's Restaurant, Inc PHONE # <br />( 530) <br />Err. <br />556-9616 <br />i <br />HOME or MAILING ADDRESS 5847 Brace Road FAX # <br />( ) <br />CITY Loomis STATE CA ZIP 95650 EMAIL Jeremy@goldenpd.com <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 or activity <br />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: <br />8/24/2023 <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Or my <br />representative. <br />TYPE SERVICE REQUESTED: 'N A OF e_ y ()Q._ -e. -C--\._ (D\ ov\ <br />IV COMMENTS: VE4 <br />AUG 2.7 <br />,,. 2023 <br />SA N JOA n <br />HE-6-NV IR6 LIIN COI 1 ACTH 0 NmE.A17.-NT EpAR , AL , mE-iv7 <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: LI., e \\-\c\(e _s EMPLOYEE #: DATE: <-6 • as . 2,3 <br />Date Service Completed (if already completed): SERVICE CODE: 5 2...., P/E: ‘ ko o 1 <br />Fee Amount: S' -4. 2G1 — Amount Pai4 <br />7 <br /> ea' .2 i. oD Payment Date <br />Payment Type \Ric__ <br />I <br />Invoice # Check # 167 7 516 34 Received By: 60---- <br />Permit Manager <br />Title <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23 \\0ç -St o1