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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />Fast Food Restaurant <br />0A 0 01 8-7 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />Quikserve Cajun Inc <br />FACILITY NAME <br />Po a es #10752 <br />SITE ADDRESS <br />4968 <br />I <br />West Lane <br />Stockton <br />95210 <br />Street Num bar <br />Direction <br />Street Name <br />CIN <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />25 <br />East Airway Blvd <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Livermore <br />CA 94551 <br />PHONE #1 EXT' <br />APN # <br />LAND USE APPLICATION # <br />(925) 292-8359 <br />og (41 / <br />PHONE V EXL <br />BOS DISTRICT <br />LOCATION CODE <br />510 378-2940 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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: „ k I. e DATE: 9/14/2021 <br />'e 'R/MA <br />PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT❑ <br />IfAPPLICANT 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 environma/¢J� I/��,,s````it__e �assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available am t4 ime it is <br />provided to me or my representative. IYAenL•.,CCN7' <br />TYPE OF SERVICE REQUESTED: Change of ownership Permit to Operate onf./ <br />COMMENTS: Ouikserve Cajun Inc took over this location as of Aug 16, 2021 $ <br />AN✓p 2047, <br />NfA TNDEp FR -A� <br />4160 <br />ACCEPTED BY:0ox-; <br />a—, EMPLOYEE M DATE: l0- ZZ <br />ASSIGNED TO:mcb� Om i ii' A. <br />EMPLOYEE#: DATE: <br />Date Service Completed (lf already completed): SERVICE CODE: t9b PIE: <br />Fee Amount: y D Amount Paid /&? OD Payment Date qZ H <br />Payment Type r /�� Invoice # Check # / a" Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />pR0sz-7(c2Z� <br />