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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fast food resturant chain selling ice cream and food <br /> OWNER/OPERATOR -- - CHEcx It BiLuNG AD4REss❑ <br /> —Virk Partnersn r _ ___._— -- — --- ---- - ---- <br /> FACIuTY NAME <br /> Dairy Queen <br /> SITE ADDRESS 9299 Thornton Rd #1 Stockton 95209 <br /> Street Number1. Direcrio" Street Name Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1634 Rose Ave <br /> Street Number Street Naar <br /> CITY STATE Zi P <br /> Ceres CA 95307 <br /> PHOtiE$1 ExT APN# LAND USE APPLICATION# <br /> (209 585-5460 _ <br /> PHONE#2 EXT EMAIL DOS DISTRICT LOCATION CODE <br /> ( ) hapyvi rk@ yahoo com ------ <br /> CONTRACTOR <br /> __CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHfcx if BILUNG ADDRESS <br /> Gur reet Singh <br /> BUSINESS NAME—Virk Partners DRA Daicy Queen (209) 585-5460 <br /> PHONE# Ex <br /> HOME or MAILING ADDRESS FAx x <br /> 1634 Rose Ave ( ) <br /> MAIL <br /> clUeres � 5307 a virk ahoo.com <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> 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 v✓ith all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws <br /> APPLJCANTS SIGNATURE: DATE: _ <br /> PROPERTY I BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY 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 above site <br /> address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provided to or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: Change of Ownership of restaurant — FG'i� 17' <br /> COMMENTS: JUN <br /> sgAt Jo 28 242 <br /> y�A�Ttio �ENCVN > <br /> RTME <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#- 621 --— DATE: 6-27-23 <br /> ASSIGNED TO: Darin Afonskai <br /> EMPLOYEE#: 9825 DATE: 6-27-23 <br /> a <br /> Date Service Completed (if already completed): SUM CODE: 61. PIE: 1602 <br /> Fee Amount: I Amount Paid /`��9 PaymerrtDate - 2 23 <br /> Payment Type Invoice# Check# 3 307 Rt,cei By: <br /> paymenL 163307914 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03!22!2;3 <br />