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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE REQUEST S <br /> Restaurant with drive thru service <br /> OWNER I OPERATOR <br /> Sunny Ghai CHErXHBILLING ADDRESS <br /> FAaurY NAME <br /> Burger Kinct <br /> SITE ADDRESS Stockton 95209 <br /> 2910alrotmurrutor Eight Mile Road <br /> HOME Or MAIDNG ADDRESS (N Different from See Address) E.Airway Blvd <br /> 25 <br /> CITY STATE AP <br /> Livermore CA 94551 <br /> PHONESI En. APNa LAND USE APPLICATIONS <br /> 1 510 ) 5735905 <br /> PHONES2 Exr. SOS DISTRICT LOCADON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> TBD CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONES Em <br /> TBD <br /> HOME or MAeuNG ADDRESS FAX$ <br /> CITY STATE LP <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 ENvU2oNMENTAL 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,STA an E s. <br /> APPLICANT'S SIGNATURE: ` DATE: 05/14/19 <br /> PnOPERTV/Busem sORNER® OPERA OR/. 'AGER ❑ OTaERAVrSoRUKDAc;RT❑ Sunny Ghai <br /> 1jAPPLJC,tAT is not the Blun+G P.Le7r,proof of authorization to sign is required Tit$, <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, the owner or operator of the p o erty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environ sessment <br /> information to the SAN JOAQUTN CouN Y ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is avail8ble e�l� e it is <br /> provided to me or my representative. p� ; <br /> TYPE OF SERVICE REQUESTED:Restaurant with drive thru service. MAY <br /> CoMMe m: SN <br /> JOA <br /> A <br /> / QUN C�yEALTypp <br /> At YAR <br /> ACCEPTED BY: /�('� ✓� EMPLOYEE S: DATE: <br /> Ase1GNED TO: L EMPLOYEES: DATE: <br /> Date Service Completed (M already completed): SERVM:E CODE: PIE: <br /> Fee Amount: Amount Pald L�S(Q Payment Date <br /> Payment Type Invoice S Check N p G( Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />