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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE/R(VICCEE REQUEST# <br /> Change of Ownership of existing Five Guys Burgers locati n _J; 0-�I�q 1i <br /> OWNER/OPERATOR JJJJ <br /> Five Guys Properties LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Five Guys Burgers&Fries#1649 <br /> SITE ADDRESS 2970 Grant Line Road Tracy 95304 <br /> Street Num ber I DlreVoV tiona CI Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Go Avalara Inc. P.O. Box 8000 <br /> Stret Number St <br /> ereel Name <br /> CITY Monsey STATE NY ZIP 10952 <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> ( 845) 285-0990 <br /> PHONIER En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jane K. Murrell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ev. <br /> Five Guys Properties LLC 45 1 285-0990 <br /> HOME or MAILING ADDRESS doAValafaInc. P.O. Box 8000 FAX# <br /> ( I <br /> CITY Monsey STATE NY ZIP 10952 <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: S� / �� DATE: 8/26/22 <br /> PROPERTY/BUSINESS OWNERL - PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Titre <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 /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at�same time it is <br /> provided to me or my representative. Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: G J <br /> change of ownership S'4AI✓0 J ?� <br /> NFA ThDq qRT CO <br /> Y <br /> NT <br /> ACCEPTED BY: Vida)PedraZa EMPLOYEE#: 6213 DATE: 8-30-22 <br /> ASSIGNED TO: Kadeanne Llnhares EMPLOYEE#: 4589 DATE: 8-30-22 <br /> Date Service Completed (if already completed): SERVICE CODE: 62 PIE: 1602 <br /> Fee Amount: 156 Amount Pai N� Payment Date 0 16 Z <br /> Payment Type ,SU--- Invoice# Check# r�9( �8j� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �I-V 5 <br />