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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST If <br />FAST FOOD RESTAURANT <br />CITY STATE ZIP <br />FA0006647 <br />NEgN� NqR� <br />OWNER I OPERATOR <br />RAKESH KUMAR <br />CHECK ifBILLING aoDREss® <br />FAGuTY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL #041363 <br />SITEADDRESS 2407 <br />W <br />MARCH LN <br />STOCKTON <br />95207 <br />tmet Number <br />1 <br />SERVICE CODE: p� r <br />P I E 400 2— <br />C <br />Amount Paid <br />HOME or MAILING ADDRESS (It Different from Site Address) <br />1118 <br />32/ 2 - <br />Payment Type <br />1 + <br />CHESS DRIVE <br />Street Number <br />beet Name <br />CITY FOSTER CITY <br />STATE CA ZIP <br />94404 <br />PHONE#1 Ear. <br />APNIt <br />LAND USE APPLICATION# <br />(650) 312 9935 <br />PHONE92 Ear. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR NIA CHECK It BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Ex . <br />HOME or MAILING ADDRESS <br />FAX If <br />( 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 ENVIRONMGN'rAl. 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 />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 <br />COUNTY Ordinance Codes, Standards, S1 ATJt19d FEDERAL laws. <br />APPLICANT'S SIGNATURE: 6y DATE: 03/10/2023 <br />PROPERrY/$USnVEss OWNER® OPERATOR/ MANAGER ❑ 0FUER A U'FNORIZE D AGENT❑ <br />If APPLICANT is not the BILLING PARTY. proof of authorization to .rign 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 environmental/site essment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the 14' <br />provided to me or my representative.Psty <br />TYPE OF SERVICE REQUESTED: YO <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />1A <br />COMMENTS: <br />REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP. <br />NEgN� NqR� <br />REQUEST FOR PERMIT TO OPERATE <br />q� <br />TME <br />ACCEPTED BY: <br />EMPLOYEE III: <br />DATE: S-20'—%3 <br />ASSIGNED TO: et Ve V-- <br />EMPLOYEE #: <br />DATE: 3- 20 2-3 <br />Date Service Completed (N already completed): <br />SERVICE CODE: p� r <br />P I E 400 2— <br />Fee <br />Fee Amount: IS(o <br />Amount Paid <br />�Sto O� <br />Payment Date <br />32/ 2 - <br />Payment Type <br />1 + <br />Invoice # <br />Check # �Sg�%G �� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />1A <br />