Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST / <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> MOBILE FOOD TRUCK S 009\*91u\ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> JOHN PATRICK NISBY <br /> FACILITY NAME <br /> PATRICK'S HOUSE CATERING <br /> SITEADDRESS E HARDING WAY STOCKTON 95204 <br /> 435 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> 1 209) 851-5230 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> VIKTOR SITAS CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT' <br /> LA CUSTOM FOOD TRUCKS <br /> HOME or MAILING ADDRESS FAX# <br /> 12345 FOOTHILL BLVD. ( ) <br /> CITY STATE CA ZIP 91342 <br /> SYLMAR <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: 03/05/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/OXN'tR-Er OTHER AUTHORIZED AGENTR CEO <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 availablak sAe time it is <br /> provided to me or my representative. R �V.. A, <br /> TYPE OF SERVICE REQUESTED:FOOD TRUCK PLAN CHECK O <br /> COMMENTS: <br /> SAN') 9 204V <br /> fNVIR QUhV C <br /> HEALTH CE ARTM Nry <br /> ACCEPTED BY: EMPLOYEE#: (0 Z4 '!3 DATE: 3 ao <br /> ASSIGNED TO: EMPLOYEE#: Co C(LF <br /> DATE: 2� <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: f(Dio I <br /> Fee Amount: Amount Pa' D Payment Date G� <br /> t <br /> Payment Type Invoice# Check# 3t' Received By: <br /> EHD 48-02-025I � SR FORM(Golden Rod) <br /> REVISED II/17/2003 ,J vy`yv, � ( sto ►�'1��-Q • u-0l <br />