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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST C)-7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Food RestaurantEA <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Quikserve Cajun Inc <br /> FACILITY NAME <br /> Po a es#12192 <br /> SITE ADDRESS 7567 <br /> Pacific Ave Stockton 95207 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS {If Different from Site Addressi <br /> 25East Airway Blvd <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Livermore CA 94551 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925) 292-8359 a —10 -19 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIQ CODE <br /> 510 378-2940 �E] <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR fig <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> (510 )3-19- 2171-10 <br /> HOME Or MAILING ADDRESS FAX# <br /> { ) <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 /> 1 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: , ; �. n DATE: 9/14/2021 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTS' 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 environmenta I assessment <br /> information to the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT'a5 soon m it is available and at k e It iS <br /> provided to me or my representative. zC N71 <br /> TYPE OF SERVICE REQUESTED: Change of ownership Permit to Operate OrrQ <br /> COMMENTS: Quikserve Cajun Inc took over this location as of Aug 16.2021 QI v Ja4 Qu <br /> ?Q <br /> CO <br /> ecpgR���NT1- <br /> ACCEPTED BY: � EMPLOYEE#: DATE: V_ 70 <br /> AIWL <br /> ASSIGNED TO: � EMPLOYEE#: DATE: 16- <br /> ZZ- <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> 464 1 <br /> Fee Amount: Amount Paid �� Payment Date /6 <br /> Payment TypeS� Invoice# Check# IJ Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rodd <br /> REVISED 11/17/2003 <br />