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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # FAST FOOD RESTAURANT FA0007021 59,MNoS22 ONMER I OPERATOR SAN✓o RAKESH KUMAR CHECK If BILLING ADDRESS® FACa1TY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL #041359 SITE ADDRESS 201 r4 N NORTHGATE DR MANTECA 95336 Street Number EMPLOYEE #: DATE: h ^^�.., 23 ASSIGNEDTO: �� HOME or MAILING ADDRESS (If Different from Site Addreea) 1118 CHESS DRIVE beet NUM Stroot Nme CITY FOSTER CITY STATE CA nP 94404. PHONE#1 APN# LAND USE APPLICATION (650) 312 9935 Invoice # PHONE #I En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR N/A CHECK it BILLING ADDRESS❑ BUSINESS NAME PHONE HOME or MAILING ADDRESS FAX # ( 1 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 HEALTH DEPARTMENT' hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that 1 have prepared this applicatio d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, $TAl" FtDERAI. laws. APPLICANT'S SIGNATURE: d __ DATE: 03/10/2023 PROPERTY/ BUSINESS OWNER® OPERATOR/ MANAGER ❑ OTHER At AGENt❑ IfdPPL1CAAT is not dee Rimm; PARTY 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 assessment information to the SAN JOAQUIN COUNTY ENYtRONMGN I'AI. HEALTH DFPARTMENI as soon as it is available and at the same time it is provided to me or my representative. _pQ VA TYPE OF SERVICE REQUEsrEO: IC COMMENTS: I'�R REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP SAN✓o HEq ON 1VCou REQUEST FOR PERMIT TO OPERATE r4 N WA ACCEPTED BY: Cu re �� 5 LG EMPLOYEE #: DATE: h ^^�.., 23 ASSIGNEDTO: �� EMPLOYEE# �'7: DATE:_!-`�+�Z Date Service Completed (If aiready completed): SERVICE CODE: ©� PIE: Fee Amount: 1S(o Amount Paid/5' r O Payment Date Payment Type Invoice # Check is I S-gyef Received By: EHD 48-02-025 REVISED 11/172003 SR FORM (Golden Rod)