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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAST FOOD RESTAURANT FA0007777 <br /> OWNER/OPERATOR <br /> RAKESH KUMAR CHECK it BILLING ADDRESS® <br /> FACILITY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL/KFC <br /> SITEADDRESS 18780 HWY 88 LOCKEFORD 1 95237 <br /> Street Number lion I StmetNarne I cityZi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1118 CHESS DRIVE <br /> Street Number Street Name <br /> CITY FOSTER CITY STATE CA ZIP 94404 <br /> PHONE 01 EXT. APN# LAND USE APPLICATION# <br /> (650) 312 9935 <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR N/A CHECK If BILLING ADORESS� <br /> BUSINESS NAME PHONE# EXT. <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 ENVIRONNIENTAI.I IFALTII DEPARI'MFN'r hourly charges associated with Iris project <br /> or activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this applicatio nd that the work to be performed will be done in accordance with all SAN J0Ae1uIN <br /> COON FY Ordinance Codes,,SJant/ards.S FATE FEDFRAL laws. <br /> APPLICANT'S SIGNATURE: D,%'I'E: 03/10/2023 <br /> I'ROPF.R'rl/BUSINESS OWNERM OPEP,%'I OR/NIANAGF.R ❑ 01111ER AUTHORIZED AGENT❑ <br /> 11':IPPLICa.roT is not the BILLING PARn',proof of authorization to sign is required rime <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 andior environmental/site assessment <br /> information to the SAN JOAUUIN COLINIY ENVIRONNIENIAI.HfiALTH DI:PARIMI::Nr as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: C�62. . r <br /> COMMENTS: RARD <br /> REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP. -SA NJ0 2 ?QZ <br /> REQUEST FOR PERMIT TO OPERATE <br /> HEALTH E gFNT�q� TY <br /> RTM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: p4�J20•I1 s EMPLOYEE#: DATE: _ <br /> Date Service Completed (if already completed): SERVICE CooE: PIE: L �O <br /> Fee Amount: `S(d Amount Pal /SIO,co Payment Date 3 <br /> Payment Type Invoice# Check# lbrB��GI Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />