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COMPLIANCE INFO_2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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1600 - Food Program
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PR0544310
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COMPLIANCE INFO_2019
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Entry Properties
Last modified
4/22/2020 8:03:53 AM
Creation date
4/22/2020 8:03:27 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0544310
PE
1636
FACILITY_ID
FA0025187
FACILITY_NAME
GALLARDO PRODUCE #5N92747
STREET_NUMBER
327
Direction
E
STREET_NAME
HAZELTON
STREET_TYPE
AVE
City
STOCKTON
Zip
95203
CURRENT_STATUS
01
SITE_LOCATION
327 E HAZELTON AVE #B
P_LOCATION
01
QC Status
Approved
Scanner
SShih
Tags
EHD - Public
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PROPERTY! BUSINESS OWNER a ..-t ATOR / MANAGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof o authorization to sign is required <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />g D 0 •0 tit° <br />cz <br />OWNER/OPERATOR 0..) ai \\ A ack/D De ksos _ 0 6151--A AMCIftBILLING ADDRESS <br />FACILITY NAME <br />CTA 0\ m,e_ao v,a, ck,,t e .e._ --V 611 012-1 L-k--1 <br />SITE ADDRESS ----2...--4.- <br />Street Number <br />f <br />Direction <br />k -}-w) As•Pe-- <br />Street Name <br />—,\--LTW-0,1 <br />City <br />0 S-1-CiN3 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C14 11AVAD 126 /S-fSW? (4Si-AWC1t(, CHECK <br />ii <br />if BILLING ADDRESS-U-01 <br />_fr <br />BUSINESS NAME n <br />,11'tP1 it A-0 WOCIA4,C/C" <br />IN 14z EXT. <br />HOME or MAILING ADDRESS - .,..„, . k3,-, 4s--1"-C3 <br />FAX # <br />( ) <br />CITY N,,V...4„.....i STATE CA ZIP (21S2 cy .41 <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 or <br />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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 1 6-1 <br /> <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assei sment information ldt <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i Vial to me Of <br />my representative. I me <br />TYPE OF SERVICE REQUESTED: Oct \KV\ t Cii \ RCSVCCIA, CV\-, '''`A'etiVED <br />COMMENTS: A ct Teaule, /' APR 0 <br />3 2019 sitivJa, envo QuiN co <br />cPAIRritigivr <br />ACCEPTED BY: 1. \Ark ,6\AG EMPLOYEE #: DATE: Li _6 12.yiji <br />ASSIGNED TO: \I ir,\ c v'1eto EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: \ PIE: IteLG <br />Fee Amount: 4, \ 0 2 . op Amount Paid Payment Date (// , <br />Received By:7-iie Payment Type (7As Invoice # Check # <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)
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