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Sf New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Site Address ZIP18011 W Grant Line Road,95391 Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other Commercial Tenant improvement for Restaurant, Shell permitted with County License Plate Number VIN Architect□ Contractor□ Billing Party □ Facility Contact □ Property Owner ^Facility Owner □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Contact If contractor, indicate type and license numberFirst Name Last name Chipotle Mexican Grill City State ZIPAddressOH 43218PO Box 182568 Columbus Phone □ Property Owner □ Contractor□ Facility Owner □ Facility Contact Architect If contractor, indicate type and license numberLast name ZIP 94111 Phone □ Property Owner □ Contractor □ Arc)□ Billing Party □ Facility Owner □ Facility Contact If contractor, indicate type and nSiLast nameFirst Name Address City State Phone EmailPhone DATE: □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER Linked FA IDAssigned ToAccepted By Kadeanne LinharesVidal Pedraza FeeDatePE 5165/5/25 1601 □ Cash □ Check # Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required (^Application for Operating Permit Email licensing@chipotle.com State California Address 500 Sansome St, Sth Floor, If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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 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. Email rn.stonikinis@inieriorarcnitects.com City Mountain House City San Francisco Phone 215-203-2890 < 'vrr W OTHER AUTHORIZED AGENT APN 209-450-35 (BUILDING 2) Type of Service Requested Comments Architect, Interior Architects Title ^Confirmation# 200580361 Record Number APa.503.QQ, 1 Payment ( Received By^d Phone 614-318-7470 trilling Party E^acility Owner State California First Name Interior Architects - to ) BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/o 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. .'I APPLICANT'S SIGNATURE: hati:. 'T/ZJ/ZD Facility Name Chipotle