My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
COMPLIANCE INFO
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
M
>
MARCH
>
1217
>
1600 - Food Program
>
PR0160164
>
COMPLIANCE INFO
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/1/2020 4:32:53 PM
Creation date
3/21/2019 9:05:15 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0160164
PE
1624
FACILITY_ID
FA0001260
FACILITY_NAME
DELI DELICIOUS
STREET_NUMBER
1217
Direction
W
STREET_NAME
MARCH
STREET_TYPE
LN
City
STOCKTON
Zip
95207
CURRENT_STATUS
01
SITE_LOCATION
1217 W MARCH LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
JCastaneda
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
50
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 12 <br /> OWNER/OPERATOR <br /> O ,`` CHECK If BILLING ADDRESS <br /> FACILITY NAME 1� <br /> SITE ADDRESS (,J_ <br /> 12— t Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / 6 ( (1 AJ LA 'c- (�C t I Street Number Street Name <br /> CITY STATE ZIP <br /> IL-ti4� '-" CLd� gtS3-?j, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE UESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADRESIS FAX# <br /> CITYSTATE ZIP <br /> JJ <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 tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILGING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operatoro �ocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or e: assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail t e same time it is <br /> provided to me or my representative. _ <br /> TYPE OF SERVICE REQUESTED: C-01 INTY <br /> COMMENTS SAENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C-- 0�k'�1 L EMPLOYEE#: DATE: <br /> ASSIGNED TO: �` \- <br /> k\NS CI \ - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: li n o 2 <br /> Fee Amount: \tea.U0 Amount Paid Payment Date V( <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />
The URL can be used to link to this page
Your browser does not support the video tag.