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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 If <br />FAST FOOD RESTAURANT <br />FA0004680 <br />jRmm>Sl$ <br />OWNER 1 OPERATOR <br />DATE: <br />RAKESH KUMAR <br />CHECK If BILLING AppRE$$® <br />FACILITY NAME <br />Dale Service Completed (B already completed): <br />KUMAR MANAGEMENT CORP. <br />II INC. DBA TACO BELL #041364 <br />SITEADORESS 864 <br />WCHARTER <br />WAY <br />STOCKTON <br />I <br />95206 <br />N M <br />Payment Type �( <br />Invoice # <br />t t Name <br />Qly <br />zipC de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1118 <br />CHESS DRIVE <br />Sirret Number <br />Street Nam <br />CITY FOSTER CITY <br />STATE CA zP 94404 <br />PHONE #I EXT. <br />APN # <br />LAND USE APPLICATION If <br />(650) 3129935 <br />PHONE 12 Exr. <br />I ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR N/A CHECK It BILLING ADDRESS O <br />BUSINESS NAME <br />PHONE # ExT' <br />HOME or MAILING ADDRESS <br />FAX If <br />I 1 <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 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,STATE EOERAL laws. <br />APPLICANT'S SIGNATURE: �_ 1?e �— DATE: 03/10/2023 <br />PROPERTY/ BUSINESSOWNER® OPERATOR /MANAGER ❑ OTHER ALTHORIZEDAGENr❑ <br />ff,4PPtu'dYT is not the BILL-1,gi PARTY. proof of authorization to sign is required <br />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 environmentallsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMF.N I At HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP. <br />REQUEST FOR PERMIT TO OPERATE <br />ACCEPTEDBY: �.5/`ft,(�SLy <br />EMPLOYEE#: <br />DATE: <br />AS31GNEDTO: Lin kar,es <br />EMPLOYEE III: <br />DATE: 7j .—�j . Z3 <br />Dale Service Completed (B already completed): <br />SERVICE CODE: <br />1 E: OZ <br />Fee Amount: tyro <br />Amount Paid �j� t <br />Payment Date <br />Payment Type �( <br />Invoice # <br />Check # /Sgy'761 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />Q O%(SLI ZJ <br />