Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# IF SERVICE REQUEST# <br /> Fast Food Restaurant 32172 SR�� 8588 � <br /> OWNER/OPERATOR <br /> Kang Foods LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Arby's#5583 <br /> SITE ADDRESS 95376 <br /> 745 Street Number Direction FWCIOVer Rd Street Name Tracy city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 39180 Liberty Street#208 Street Number Street Name <br /> CITYSTATE ZIP <br /> Fremont CA 94538 <br /> PHONE#1 Enc APN# LAND USE APPLICATION# <br /> (510 )790-8204 214-180-180-000 <br /> PHONE#2 E%. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 pe ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4 DATE: 9/26/2022 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ER 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and�[A y` ne time it is <br /> provided to me or my representative. H rPpp <br /> TYPE OF SERVICE REQUESTED:Change of Ownership I rispection �Ep <br /> COMMENTS: UUT 0 7 <br /> SAN JCA QUI < <br /> kEgLTH pE AR M NTy <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L ; EMPLOYEE#: '--k51601 I DATE: , ^�—',^2 2— <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: 0 bPIE: l b O <br /> Fee Amount: \c) � Amount Pai /-%.v Payment Date /t7 <br /> Payment Type i Invoice# Check O`] 2 9 Rei5eivied By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />