COMPLIANCE INFO_2023 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID M SERVICE REQUEST # FAST FOOD RESTAURANT FA0002197 6(v515 OWNER / OPERATOR CHECK If RAKESH KUMAR BILLING ADDRESS® FACILITY NAME KUMAR MANAGEMENT CORP. II INC. DBA TACO BELL #041345 SITE ADDRESS 3507 W HAMMER LN STOCKTON95219 N.. c a HOME or MAILING ADDRESS (If Different from Site Address) 1 1 1 8 CHESS DRIVE S4b Street N me CITY FOSTER CITY STATE CA ZIP 94404 PHONE *1 ErT' APR a LAND USE APPLICATION N 11650) 3129935 PRONE#2 BOS DISTRICT LOCATION CODE 11 ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR WA CHECK it BILLING ADDRESS BUSINESS NAME PHONE N Ear_ HOME or MAILING ADDRESS FAXN CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some. acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S 'ATF FhDERAL laws. APPLICANT'S SIGNATURE:,DATE: 03/10/2023 PROPERTY/BUSI.NESSONNER® OPERATOR /MANAGER❑ OTHER AUTHORIZED AGENT [3 IjAPPL/CAN7 is not the B11.1 -MG PART' proof of authorization to sign is required Tine 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 environmentakite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it is available and at XL'��jII�mC it is provided to me or my representative. ��,� JY//QA,_ TYPE OF SERVICE REQUESTED: COMMENTS: REQUEST AN INSPECTION PRIOR TO CHANGE OF OWNERSHIP REQUEST FOR PERMIT TO OPERATE 44 rNDEAgRT gF�TY Nl ACCEPTED BY: Cc'VfU tS '-'C, EMPLOYEE DATE: S -ice rL'; ASSIGNED TO: rz .v ' Z EMPLOYEE 9: DATE: 3 -XZ.() X" Date Service Completed (If already Completed): SERVICE CODE: 06 PIE: lfOf�L Fee Amount (5(o Amount Paid 156. Q� Payment Date 311(12.3 Payment Type (T in, e Invoice /t Check If I <-x7671 j/,4 Received Bv: EHD 48-02-025 REVISED 11/1712003 SR FORM (Golden Ron)