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SAN JOAQUIiv COUNTY ENVIRONMENTAL HEALTAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Quick Serve Restaurant(Carl's Jr.) �V-l.�v L'S 2 & s <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> TWM Industries <br /> FACILITY NAME <br /> Carl's Jr. # L(S SITE ADDRESS 260 GA Tn/of <br /> Street Number Direction Street Name City <br /> 1 Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 899 Cherry Ave. <br /> Street NumberStreet Name <br /> CITY San Bruno STATE CA ZIP 94066 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 560 ) 583-6491 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Greg Swanson CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT_ <br /> Total Pro'eX Corporation 909 873-1088 <br /> HOME Or MAILING ADDRESS FAX# <br /> 1426 S. Willow Ave. ( 909) 873-0802 <br /> CITY Rialto STATE CA ZIP 92376 <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 1 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: 7-9-2012 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: Final Inspection for New Carl's Jr. Kitchen Equipment for Biscuit Program <br /> COMMENTS: <br /> New equipment includes (2) stacked ovens, oven timers, a Hatco warming unit to keep the biscuits warm <br /> after they are cooked and a prep area made up of a stainless steel prep table and a mixing bowl used to <br /> mix the dough by hand. <br /> ACCEPTED BY: EMPLOYEE#:(q DATE: <br /> ASSIGNED TO: — N' I��j I ,V—\ EMPLOYEE#: L► ?,C)� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CJS PIE: <br /> Fee Amount: 1 U l✓ Amount Paid / P "Ite — 1 <br /> i <br /> Payment Type Invoice# Check# '� Re eiv d By: <br /> h JUL 10 20; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />