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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILffY ID # <br />PHONE # En. <br />SERVICE REQUEST # <br />FAST FOOD RESTAURANT <br />FA0002914 <br />No pAR MEY <br />SRmmBroS I (o <br />OWNER I OPERATOR <br />ACCEPTED BY: Cc[ v f� t <br />RAKESH KUMAR <br />DATE: <br />CHECK It BILLING ADDRESS <br />FACILITY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL #041348 <br />SITE ADDRESS 532 <br />W <br />HAMMER LN <br />STOCKTON <br />I <br />95210 <br />SUne[Number <br />Direcllon511eot <br />/2. t <br />Nam. <br />Payment Type <br />OwG <br />e <br />HOME Or MAILING ADDRESS (It Different from Site Address) <br />1118 <br />CHESS DRIVE <br />Street Number_ <br />St,"t Name <br />_ <br />CITY FOSTER CITY <br />STATE CA Zip 94404 <br />PHDNE#I Ev. <br />APN# <br />LAND USE APPLICATION# <br />(650) 312 9935 <br />PHONE #2 Ev. <br />( <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR N/A CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 nee 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, STA 'I - FEDERAL laws. <br />APPLICANT'S SIGNATURE: E�r�//p�//`yL� DAA,.: 03/10/2023 <br />PROPER'r1'/ BITSINYti5OWNER® OPERATOR/ MANAGER ❑ OTHER AcTlimuzED AGENT 13 <br />1f APPLICANT is not (he BILLING PAR77proof of authorization to sign is required Tltir <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 environmental/site assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at l 1� e_ time it is <br />provided to me or my representative. 2 r/Vjr., <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />/,? <br />REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP. s 4 N ogQIJ/ �23 <br />yeALT <br />REQUEST FOR PERMIT TO OPERATE <br />No pAR MEY <br />NT <br />ACCEPTED BY: Cc[ v f� t <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: eµ kr-.-- <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: ('(p <br />P 1 E: �p 2 <br />Fee Amount: M(o <br />Amount Paid <br />/2. t <br />Payment Date 312/ X3 <br />Payment Type <br />Invoice # <br />I <br />Check At 67gy'%&)4 <br />n. <br />1 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />