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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Change of Ownership of existing Five Guys Burgers locati n O C f OI lgl;lr� <br /> OWNER OPERATOR V IH VBILLI "1 <br /> Five Guys Properties LLC CHECK If BILLING ADORE55E] <br /> FACILITY NAME Five Guys Burgers& Fries#1172 <br /> SITE ADDRESS 5633 Pacific Ave Stockton 95207 <br /> Street Number I Decon � I CIN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c/o Avalara Inc. P.O. Box 8000 Streal Number trees Name <br /> CITY Monsey STATE NY ZIP 10952 <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> ( 845) 285-0990 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jane K. Murrell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM. <br /> Five Guys Properties LLC 45 1 285-0990 <br /> HOME or MAILING ADDRESS c/o Avalara Inc. P.O. Box 8000 FAx# <br /> 1 ) <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: WeA� �/ DATE: 8/26/22 <br /> PROPERTY/BUSINESS OWNERL PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING 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 t0 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. A <br /> TYPE OF SERVICE REQUESTED: JVJFr IV TF <br /> COMMENTS: <br /> change of ownership SAIV AUG 30 ?�22 <br /> ffEq TH p PART/y NTy <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 8-30-22 <br /> ASSIGNEDTO: Lydia Baker I <br /> EMPLOYEE#: 9818 DATE: 8_30-22 <br /> Date Service Completed (If already Completed): 44 SERVICE CODE: 62 PIE: 1602 <br /> Fee Amount: 156 Amount Paid Y701SI..no Payment Date E 12 <br /> Payment Type Invoice# Check# I D Received By: <br /> illa— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />