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COMPLIANCE INFO_2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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PR0544895
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COMPLIANCE INFO_2019
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Last modified
4/15/2020 8:59:11 AM
Creation date
4/15/2020 8:58:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0544895
PE
1635
FACILITY_ID
FA0025524
FACILITY_NAME
MOES BURGERS N PHILLYS FOOD TRUCK #50383B1
STREET_NUMBER
2900
Direction
E
STREET_NAME
HARDING
STREET_TYPE
WAY
City
STOCKTON
Zip
95205
APN
14310020
CURRENT_STATUS
01
SITE_LOCATION
2900 E HARDING WAY
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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EHD - Public
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SAN JOAQUIN l..IUNTY ENVIRONMENTAL HEALTH Du. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 120 <br /> OWNER/OPERATOR <br /> �2 .� I`f ' /t/��j� ` CHECK If BILLING ADDRESS <br /> FACILITY NAME mo�5 1;jt -1 're S N ! '�1► `r (`l�� tS Jv��j 'J <br /> SITE ADDRESS -2-A 'E� 1 ^r � W AN -T <br /> Street Number Direction reet Name Ci f✓ p Zi Code <br /> 2-1 <br /> HOME or MAILING ADDRESS (If Different from Site Address) LA ��c�)/� U C-1 4/� "e <br /> J Street Number Street Name <br /> CITY ��; _ STATE 1 ZIP <br /> PH NE#1Exr. APN# LAND USE APPLICATION# <br /> LIS <br /> ,2 <br /> PHONE#2 EXT. 130S DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> M / 1 C A n' -c QiCHECK if BILLING <br /> BUSINESS NAME PHONE# EXT. <br /> moel'; "r9 <br /> HOME or MAILING ADDRESS FAX# <br /> l (� Gi 1110 C�2 Lc— <br /> CITYC ( ) <br /> V-111J STATE ZIP C��Zi <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 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE andFE L laws. <br /> APPLICANT'S SIGNATURE: / ,y DATE: 5, <br /> PROPERTY/BUSINESS OWN ER OPERATOR/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 <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. PAY <br /> TYPE OF SERVICE REQUESTED: a�5 �. ECEI" <br /> COMMENTS: <br /> SEP Z 5 2019 <br /> S ONt N <br /> NRCOUNTY <br /> HEALTH pR Ae 7AL <br /> ACCEPTED BY: `` _ EMPLOYEE#: DATE: Ot <br /> ZS <br /> ASSIGNED TO: \� V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ao 1 PIE: 3 <br /> Fee Amount: `(�L Amount Paid Payment Date c <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 T SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />
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