|
zip
<br />40205
<br />rr,t ?vamp last namr. If .rontr t1 o' indicate type ano license nuirtier
<br />Patrick Fink
<br />Adores% ty ZIP
<br />c
<br />Cr
<br />/o Texas Roadhouse, 2422 Naglee Road Tracy 95304
<br />Phione Phone
<br />209-830-1133 store_tracy@texasroadhouse.com
<br />BILLING ACKNOWLEDGEMENT: I, the unciersdred property ni ot.5iness owner, operator nr aranonzed agent of .ame, .aknowaregt, Vat ii ..te anrii,-,r project
<br />:pert ,fic ENVIRONMENTAL HEALTH OCPAP:71,4(NT hourly Charges ass ai,ated wan this tvwct or 4;:tnaty wiq be brJ$.rx-is
<br />form
<br />Sh:te:
<br />CA
<br />Docusign Envelope ID: 9E103232-0B1AABF5-9819-1AEEB2C1736C
<br />San Joaquin County Environmental Health Department
<br />Application Form
<br />Appf st L: - ngt: of lJw"c 0reethil,i or Etemoriel Qthei
<br />Over,: ,:f.
<br />Change of ownership effective January 1, 2025. No changes to facilities or day to day operations.
<br />o..-eoer truth
<br />Contaa mes t3JJng Party j./C. .rjr Owne,.
<br />required
<br />
<br />, PrIghorty Own i Crwqr;4; tor 0 Archiuni
<br />
<br />; BaIing Party 7.1 Eacirty Ownei 0 I:az.,;ity Cons.ict tlCont'artur Ar7chite-ct-- —
<br />
<br />Cte Lvcre ane I,cense numper
<br />Texas Roadhouse Support Center - Attn: Legal Dept. - Licensing
<br />Addie5i, City `It.r*t• 6040 Dutchmans Lane Louisville KY
<br />Phone FnA!
<br />502-426-9984 katie.mcculliun@texasroadhouse.com _ .
<br />'0 CI 'g art - kaz.niez CuntarE Rioderty E.1 Cone:artor
<br />' Eittt Name • Last name ,II rz,ntiz.z.lor
<br />_ _ _
<br />Texas Roadhouse.
<br />24/2 Nagiee Road
<br />D‘Str;CI
<br />Tracy
<br />_
<br />110
<br />95304
<br />. _
<br />Fist Name
<br />Texas Roadhouse Holdings La rd arW
<br /> Pities tor, .ndir.ale type. and I,tenu.• number
<br />- -
<br />Adlress 6040 Dutchmans Lane ioutsville
<br /> ea via
<br />KY
<br /> 75'
<br />40205
<br />rie
<br />502-426-9984
<br />
<br />katie.mccullurneaexasroadhouse.corn . _ r Pu g Pa: t -'ac,lay XFAr:lity Contact nproperiv (. Oritr.ir to,
<br />
<br />AA I also certfv tnat I have • 1/77144fPRAMPW:40r, aru /hat the wc:k to bi. etdoJrned wIl be done m at/or:rani e war ell SAN JOAQUIN COUNTY Oro , ani e Ci
<br />. Siandaid,c, STATF anti FE )t litil b-ct:.: f2tvumlf
<br />ISr. Texas Roadhouse, Inc.. Its ManageT
<br />I-exas Roadhouse I irrlaings 1.1C - I I 4 6b • lak.A ,
<br />APPLICANT'S SIGNATURvirr tk. 41:.--Y—•=1-9----- ---.8E36E5CD26A348A ltif-AISTiTITerlilett. OtrIctor of rIcktISITIIESEritirtifi'rroinpfirtia"
<br />0 `, 'it• .r).
<br />NaROPERTY / BUSINESS OWNER CJ OPt RATOR I MANAGI. 4 :3 OTHiR AV7N041ZE I) AGLNT 44 A r) . : . t I e vV ../ 8
<br />.;,NT s not the BILEING PART'f. pro& of authorization to sigh ,!.. reouire-d ,4 ,, ,, .....,/, t9/22
<br />AuTfloinZATYON ro RELEASE INfORMATION: When aopticable, I. the Owner Of oprraior of the prooe,ly located ji roe ii/cr" '..'!, :0-i,,•,,':,• '-' ' ' ,
<br />release of any and all resultS, geotechnical data ar.4/or environmental/site avieJwrrient information to to SAN JOAQUIN COUNTY ENVIRONV : I At Hi
<br />? _DEPARTMENT as soon a: ,t .iyailabie and at the same time Is ofcr.rded to roe or iny representem•
<br />-4,114
<br />\ -+_cL2.-
<br />; Payment
<br />0 Cash 10 Check C Confirm:Joon \( ReCeized
<br />; Accepted By A5signed To I Linked FA ,0
<br />VrAgi r
<br />Date PE Fee nu: Numbs?'
<br /> kke3,02_ 5R2L-VD008-1-
<br />gev 07:1012024
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