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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY 10 SERVICE REQUEST It FAST FOOD RESTAURANT !# FA0001221 S1200NOS21 OWNER/ OPERATOR RAKESH KUMAR CHECK if BILLING ADDRESS® FACa1TY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL #041341 SITE ADDRESS 421 E YOSEMITE AVE MANTECA I 95336 SveeTNemtNf city Zip Cod, HOME or MAILING ADDRESS (If Different from Site Address) 1118 CHESS DRIVE Stoat NYmIMrStrv� Name CITY FOSTER CITY STATE CA ZIP 94404 PHONE #1 ETR. APN a LAND USE APPLICATION 0 ( 650) 312 9935 PHONE N2 EYr. SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR N/A CHECK If BILLING ADDRESS BUSINESS NAME NONE Ea T. HOME Or MAILING ADDRESS FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEAIa'R DFPARTMPNT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Cades, Standards, STA" d FEDERAL laws. APPLICANT'S SIGNATURE: ,t. — DATE: 03/10/2023 PROPERTY / BUSINESS ON'NEN® OPERATOR / MANAGER ❑ OTHER Autruca17.r.D AGrVT❑ /fAPPLIL'M'7 is not the BILLING PARTI'. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site Lssessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMEN t' as soon as it i5 available and at thec1('8�fdluK provided to me or my representative. .��/C TYPE OF SERVICE REQUESTED: COMMENTS: REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP, REQUEST FOR PERMIT TO OPERATE ACCEPTED BY: AssuomED TO: -FR k M Date Service Completed (if already completed): Fee Amount: IS (o Amount Paid Payment Type /'Ipo,J /- I Invoice M EHD 48-02-025 REVISED 11/172003 EMPLOYEE #: EMPLOYEE #: SERVICE CODE: 0421 Payment Date Check If Isgy,%/04 �p102, DATE: % 2L ,.,2 DATE: "2_0 " PIE: 3 z Received By: SR FORM (Golden Rod)