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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 2 D 5 y7 ;L /2- <br /> Type of Business or Property FACILITY ID# T� Saoogl-410-z <br /> SERVICE REQUEST# <br /> Restaurant ��}()QZ(o �Gj 3 <br /> OWNER/OPERATOR <br /> Fujisan Franchising Corp. CHECK If BILLINGADDaESs❑ <br /> FACILITY NAME Fujisan Sushi <br /> SITE ADDRESS sol Presidents Drive SMcMon 95211 <br /> Street Number I Direction Street Name city 730 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 14420 Bloomfield Avenue <br /> Street Numbar Street Name <br /> CITY Santa Fe Springs Sy zip <br /> 90670 <br /> PHONE#I En. APN# LAND USE APPLICATION# <br /> (562 ) 404-2590 ext 7162 <br /> PHONE 92 Eu. BOS DISTRICT LOCATION CODE <br /> (858 )829-6457 i 1� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Maffei Deoramp0 CHECK If BILLING AODRrS3 <br /> BUSINESS NAME PHONE# ED. <br /> M oe N�nI G FDu)Disan Franchising Corp. 562 4012590 ext.7152 <br /> Ho <br /> 45[0 Bloomile d A eE ue SAX# ) <br /> Cin' Santa Fe Springs STATE CA ZIP 90670 <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: � DATE: 8/17/2021 <br /> Food Safety Compliance&License Mgr <br /> PROPERTY/BUSINESS OWNER OPERATOR/—MANAXAe OTHER AUTHORIZED AGENT El <br /> /rAPPLICANT is not the BlLLTNG 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 ENv[RoNMENT'AL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> A t1- <br /> TYPE OF SERVICE REQUESTED: ve--J <br /> COMMENTS: <br /> 406"C/ ?�l <br /> F 1. aeo�amPo @ �; �rG1IIt�/5/t1G1 corp , 6o.-.-7 V/TH00PgRT t Nry <br /> Irl G l <br /> ACCEPTED BY: EMPLOYEE#; DATE:ierrtA4.6Co NT <br /> ASSIGNED TO: F10LA V--CUA EMPLOYEE 9: DATE: <br /> Date Service Completed (if already completed): SmCECODE: PI E:_I�(�jp 1 <br /> Fee Amount: — Amount Pal (0 ()D Payment Date <br /> 2e <br /> Payment Type f Invoice# Check# 13d2GR ceive By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />