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Page 1 of 2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> FAST FOODk9 2 <br /> OWNER/OPERATOR <br /> JIVTESH GILL CHECK If BILLING ADDI <br /> FACILITY NAME <br /> KRISPY KRUCHY CHICKEN <br /> SITE ADDRESS 2 -L, (0(0-0Gc51 SCf1ULTE ROSTRACY Vii`'-i7� <br /> Street Number Direction Street Name Cf[ Zi> <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Nurn6r.r Street Namr. <br /> CITY STATE ZIP �A <br /> Inup <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# I� VJ- <br /> (Z�a ' 209-44-033 Cc.11/6 <br /> PHONE#2 EXT. BOS DISTRICT <br /> !$ANn 8 <br /> CONTRACTOR / SERVICE REQUIISTORH FNV/&QU/JVCOUN7y <br /> pq C <br /> REQUESTOR ANGEL ZAPIEN CHECK if BILL NG x T <br /> BUSINESS NAME PHONE# <br /> COMMERCIAL ARCHITECTURE INC. 20!) 1 571-8158 <br /> HOME or MAILING ADDRESS FAX# <br /> 616 14TH STREET I ) <br /> CITY STATE ZIP <br /> MGCtS I u t,A 95354 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT houriv charges associated with th <br /> or activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> CouNTY Ordinance Codes,Standards,STATand f DERAL laws, <br /> APPLICANT'S SIGNATURE: •I DAF: �3a�( <br /> PROPER'I'S'/BUSINESSON%NLR❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTV <br /> If it PPLICANT 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 loca <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: iltip�� r YI1'T� < <br /> COMMENTS: <br /> ACCEPTED BY: / EMPLOYEE#: DATE:` Z <br /> ASSIGNED TO: --1"A l �Li �_ EMPLOYEE#: DATE:. (t <br /> L t <br /> Date Service Completed (if already completed): SERVICE CODE: ) P 1 <br /> Fee Amount: - Amount Paid5�, v(� Payment Date41 g <br /> As <br /> P P Y �tii=' a"p31 1 .. <br /> htts:// ersonal.filesan where.com/VW/Elink/COMMARC ea 1� lic at df.l 11/30/2018 <br />