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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAST FOOD RESTAURANT <br />FA0007575 <br />SRx8(05n <br />OWNER I OPERATOR <br />LLJ <br />RAKESH KUMAR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME KUMAR MANAGEMENT CORP. <br />II INC. DBA TACO BELL #041369 <br />SITE ADDRESS 45 <br />E <br />HARDING WAY <br />STOCKTON <br />95204 <br />ACCEPTEDBY: �GeY/'tA Cjc) <br />EMPLOYEE#: <br />City <br />ZIPC.d. <br />HOME or MAILING ADDRESS (it Different from Ske Address) <br />1118mEer <br />CHESSDRIVE <br />1 DATE:S —'ZZ;1 --a 3 <br />Street Na <br />treat Name <br />Cm FOSTER CITY <br />STATE CA Zip 94404 <br />PHONE #1 En' <br />APN If <br />1Amount Pal <br />LAND USE APPLICATION # <br />(650) 3129935 <br />Payment Type 6e4 1 <br />Invoice # <br />PHONE 02 <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR if SERVICE REQUESTOR <br />REQUESTOR NIA CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME Or MAILING ADDRESS <br />FAX# <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, <br />acknowledge that all site and/or project specific ENVIRONMEN IAL 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 />1 also certify that 1 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, STATd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 03/10/2023 <br />PROPERTY/ HUSINESSOWNER® OPERATOR / MANAGER ❑ (YfHER AUTHORILEDAGF.NT❑ <br />If APPLICANT is not the BILLING PARTY. Proof Of atfthOrization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmenal/site assessment <br />information to the SAN JOAQUIN COONTY ENVIRONMENTAL HEM.TTt DEPARTMENT as Soon as It is available and al F� e it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />ED <br />COMMENTS: <br />MAR 12023 <br />SAN <br />REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP. <br />Me �rIRONMECoN`Nry <br />HOEPgTMENT <br />REQUEST FOR PERMIT TO OPERATE <br />ACCEPTEDBY: �GeY/'tA Cjc) <br />EMPLOYEE#: <br />Dim: 3-2.0 ,.Z <br />ASSIGNED TO: a k e v- <br />EMPLOYEE #: <br />1 DATE:S —'ZZ;1 --a 3 <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />COW IF <br />PIE: t W o 2 <br />Fee Amount: l5(,, <br />1Amount Pal <br />/5Z. DC I <br />Payment Date '/21/2-3 <br />Payment Type 6e4 1 <br />Invoice # <br />Check # /5-99'74/6q <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Roo) <br />REVISED 11/17/2003 <br />