Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# Q'S((E6V REQUEST# <br /> Health Center/Gym � 002019 3 sl` �"7-Z'�-q <br /> OWNER/OPERATOR <br /> Full Package LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> World Gym <br /> SITE ADDRESS East St. Tracy 95376 <br /> 2340 Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Walnut Ave. <br /> 1413 Street Number Street Name <br /> CITY STATE Zip <br /> Patterson Ca. 95363 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (831 )B40-3713 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 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: Arlene TSUJI DATE: 8/24/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ owner <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: C�/VE6 <br /> sAN AUG 31 ?OZO <br /> AL DDNMFNOUNI Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: MFN7. <br /> ASSIGNED TO: i ,e EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: b O� <br /> Fee Amount: 1 Amount Pai �Sa.O Payment Date $ <br /> Payment Type CC Invoice# Check# �9 Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />