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Owner / Operator Diversified Restaurant Group <br />Facility Name Taco Bell <br />Street Number <br />Street Number <br />City State <br />Ext.Land Use Application # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Roxanne Berlien <br />Ext.Business Name CPG <br />Home or Mailing Address 12 Turnberry dr ) <br />City Zip 92679Goto de caza <br />work to be perfonned will be done in accordance with all San JOAQUIN <br />11/7/23APPLICANT’S SIGNATURlp <br />Type of Service Requested: <br />Comments: <br />Date:Employee#:Accepted By: <br />Date:Employee#:Assigned to: <br />Service Code:l ye> ( <br />Fee Amount: <br />Invoice # <br />SR FORM (Golden Rod) <br />P£25c(WZ_ <br />Phone#2 <br />( ) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />BILLING ACKNOWLEDGEMENT: I, 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 />I also certify that I have prepare* <br />COUNTY Ordinance Codes, Stall <br />Type of Business or Property <br />Taco Bell Restaurant <br />Site Address <br />1102 <br />Phone#1 <br />( 310)407-9789 <br />International Parkway <br />Street Name <br />SERVICE REQUEST# <br />SftGXimqca'S <br />95377 <br />Zip Code <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Direction _______________ <br />Home or Mailing Address (if Different from Site Address) <br />H- <br />> t <br />P/E: <br />Received By: <br />Street Name <br />Zip <br />Permit management comp <br />Title <br />Payment Type yj <br />Phone# <br />( 310 1407-9789 <br />Fax# <br />______(_ <br />State CA <br />Go______ <br />I—/a. _____ <br />Date Service Completed (if already completed): <br />Payment Date <br />Tracy <br />City <br />Amount Paid/T <br />Check if Billing Address E3 <br />Check if Billing Address LU <br />his application and bfD <br />State anckFEoj r <br />APN # <br />20948005 <br />Date: <br />Property / Business OwnerD Opera tor / Manager O O i her Au thorized Agent 13 <br />If APPLICANT is not the Billing Party, proof of authorization to sign is required <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 environmental/site assessment <br />information to the San Joaquin County Environmental Health Department as soon as it is available and at thasame time it is <br />provided to me or my representative. Yf\/JPKl"r <br />Pk-X S/-PC <br />NOV08 2023 <br />727 <br />Check#