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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SSEERVICE REQUEST# Change of Ownership of existing Five Guys Burgers locati n Da`-31CI �--'I`'V O35 1 OWNER OPERATOR Five Guys Properties LLC CHECK If BILLING ADDRESS❑ FACILITY NAME Five Guys Burgers&Fries#1661 SITE ADDRESS 2640 1 Reynolds Ranch Pkwy Lodi 95240 Street Number I DIr.cfl.ntenet Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) c/o Avalara Inc. P.O. Box 8000 Street Number Street Name CITY Monsey STATE NY ZIP 10952 PHONE#1 EXT. APN# LAND USE APPLICATION# ( 845) 285-0990 PHONE#2 Ev. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Jane K. Murrell CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Five Guys Properties LLC 45 1 285-0990 HOME Or MAILING ADDRESS Go Avalara Inc. P.O. Box 8000 FAX# ( ) CITY Monsey STATE NY ZIP 10952 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: w_.�_//�_ii�� DATE: 8/26/22 PROPERTY/BUSINESS OWNERL PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 I,fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and Rr,4QaA1J�1e time it i5 provided to me or my representative. R 7'rvYf/:Ec TYPE OF SERVICE REQUESTED: CO COMMENTS: P'UU 30 change of ownership SAN,,O ?�22 HEgLCOO Ty p�PgRTM Alry L ACCEPTED BY: Vidal PedraZa EMPLOYEEM 6213 DATE: 8-30-22 ASSIGNEDTO: DaryaAfonskaia EMPLOYEE 9825 DATE: 8-30-22 Date Service Completed (If already completed): SERVICE CODE: 62 P I E: 1602 Fee Amount: 156 Amount Paid Payment Date 3� 2— Payment Payment Type 5&-- Invoice# Check# Recelve By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003 V2�s3 �SS1