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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VICE REQUEST# <br /> Fast Food Restaurant F4 000213ly? ] SZ(30 '95893 <br /> OWNER/OPERATOR <br /> Kang Foods LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Arby's#7447 <br /> $ITE ADDRESS <br /> 6248 Pacific Ave Stockton 95207 <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 39180 Liberty Street#208 Street Number Street Name <br /> CITY STATE ZIP <br /> Fremont CA 94538 <br /> PHONE#1 EHL APN# LAND USE APPLICATION# <br /> (510 1790-8204 081-360-020-000 <br /> PHONE#2 E,rr. BOS DISTRICT LOCATON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> ( 1 <br /> CITY STATE ZIP <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 prepared this application and that the work to be pe ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4 DATE: 9/26/2022 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ ER AUTHORIZED AGENT <br /> IfAPPLLCANT is not the BILLINGPARTY proof of authorization to sign is required 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 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:Change Of Ownership Inspection M <br /> COMMENTS: <br /> D <br /> Oct 0 <br /> 8.4/VJOA 1 20 <br /> yEA Ty pO4ENO�NTY <br /> ACCEPTED BY: EMPLOYEE#: G DATE: <br /> ASSIGNEDTO: 4-yCUa- 8 EMPLOYEE#: DATE: ! , <br /> Date Service Completed (if already completed): SERVICE CODE: 069/ PIE: 6 6 <br /> Fee Amount: I5("1 Amount Paid v5(p Payment Date /U 7 ::eD-oL <br /> Payment Type CIWJT Invoice# Check# Z Received By: <br /> COh Qln"ffn S/O <br /> EHD 48-D2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />