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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# E,RVICE REQUEST# <br /> :locatifn Change of Ownership of existing Five Guys Burger3 A v� '�J�/J� 5—�L/ <br /> OWNER/OPERATOR <br /> Five Guys Properties LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Five Guys Burgers&Fries#1801 <br /> SITE ADDRESS 2140 Daniels Street Manteca 95337 <br /> Street Number I Direction I Street ame CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c/o Avalara Inc. P.O. Box 8000 Street Number Street Name <br /> CITY Monsey STATE NY Zip 10952 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 845) 285-0990 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jane K. Murrell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> Five Guys Properties LLC 1 45 285-0990 <br /> HOME or MAILING ADDRESS c/o Avalara Inc. P.O. Box 8000 Fax# <br /> l 1 <br /> CITY Monsey STATE NY Zip 10952 <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 /> 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: �.5'�/��/i 0��� DATE: 8/26/22 <br /> PROPERTY/BUSINESS OWNERL PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLicANT is not the B/LLING 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 ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: F <br /> COMMENTS: CD <br /> change of ownership ALL <br /> SAlv.JO 3� M22 <br /> II LT Di PARTo�M7y <br /> ACCEPTED BY: Vida)PedraZa EMPLOYEE M 6213 DATE: 8-30-22 <br /> AsSIGNEDTO: Gehane Fahiny EMPLOYEE 8788 DATE: 8.30_22 <br /> Date Service Completed (if already completed): SERVICE CODE: 621 PIE: 1602 <br /> Fee Amount: 156 Amount Paldc74Q.00 Payment Date <br /> Payment Type Invoice# Check# 14-909/ 37S I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />