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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Food Restaurant <br /> C -("0-161 5(,(10 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Harman Management Corporation ❑ <br /> FACILITY NAME <br /> KFC-Store#206-Cooley 206 Inc <br /> SITE ADDRESS Stockton <br /> 3264 W Hammer Lane 95209 <br /> t Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 199 1 St Street, Suite 212 <br /> 199 1 st Street, Suite 212 Street Number Street Name <br /> CITY STATE ZIP <br /> Los Altos CA 94022-2767 <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> ( 65d 941-5681 082-400-100-000 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS 0 <br /> Laura Keriazakos <br /> BUSINESS NAME PHONE# ExT' <br /> BTS Site Services (972)f89-6751 <br /> HOME or MAILING ADDRESS FAX# <br /> 1811 Ma dale Drive ( ) <br /> CITY Dallas STATE TX ZIP 75208 <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 <br /> or activity 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: Z Gl X- <br /> jjz� d DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/1NANAG. ❑ :� <br /> OTHER AUTHORIZEDGF:VTPermitting Project Manager <br /> 1 9 <br /> � <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Food Plan Check <br /> COMMENTS: L L _ ` j �'� D <br /> skp 0 6 <br /> N4/o 201 <br /> /y, W/, ON/N COU <br /> y pF MFNr N <br /> ACCEPTED BY: � EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: S i <br /> Date Service Completed (if already completed): SERVICE CODE: S Z P!E: <br /> Fee Amount: S� � Amount Pai O Payment Date <br /> Invoice# Ch #Payment Type � Re slued By: <br /> EHD 48-02-025 �j� C C SR FORM(Golden Rod) <br /> REVISED 1111712003 ` <br />