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y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Food Restaurant �9 S2 t�n1 Sq S <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Harman Management Corporation <br /> FACILITY NAME <br /> KFC -Store#278 - Payne 278 Inc. <br /> SITE ADDRESS <br /> 1211E, Yosemite Avenue Manteca 95336 <br /> Street Number Direction I Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 199 1st Street, Suite 212 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Los Altos CA 94022-2767 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (650 ) 941-5681 208-260-20 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR//SERVICE REQUESTOR <br /> REQUESTOR Laura Keriazakos -/� ,J C/ ^��� CHECK If BILLING ADDRESS <br /> �(-�(�T 'K:/ .7 <br /> BUSINESS NAME PHONE# Ems' <br /> BTS Site Services 972 589-6751 <br /> HOME or MAILING ADDRESS FAX# <br /> 1811 Marydale 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 6bLUbQi /14/ZGCL 01 62 DATE: 9/4/18 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <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 theSame time it is <br /> provided to me or my representative. hap.- <br /> TYPE OF SERVICE REQUESTED: Food Plan Check v <br /> COMMENTS: L�l y ( S 06 <br /> �p <br /> &0071�7 9�/��t� y EiVUiNCO <br /> t Z- pMFV rA H <br /> 9�0 STM Nr <br /> /Z <br /> ACCEPTED BY: (�� ,��L/yt�^� EMPLOYEE#: DATE: 4? 5 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 11 <br /> Date Service Completed (if already completed): SERVICE CODE: 13--7,3 PIE: ` � O i <br /> Fee Amount: 7S , D Amount Pai '� D� Payment Date G <br /> Payment Type ��, Invoice# Ch k# BD Received By: <br /> EHD 48-02-025 C (✓ . SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />