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COMPLIANCE INFO_2016
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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1600 - Food Program
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PR0541440
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COMPLIANCE INFO_2016
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Entry Properties
Last modified
1/6/2021 8:19:19 AM
Creation date
1/6/2021 8:14:52 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2016
RECORD_ID
PR0541440
PE
1635
FACILITY_ID
FA0023754
FACILITY_NAME
CATERING MASTERS #5V94732
STREET_NUMBER
1717
Direction
S
STREET_NAME
UNION
STREET_TYPE
ST
City
STOCKTON
Zip
95206
APN
16904012
CURRENT_STATUS
02
SITE_LOCATION
1717 S UNION ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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SJGOV\jcastaneda
Tags
EHD - Public
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• <br />SAN JOAQUI1 COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />P001) )a)04 <br />FACILITY ID # <br />A) tW <br />SERVICE REQUEST # <br />3R oF7 lvD-(1) ti <br />OWNER! OPERATOR <br />in u P,P4 E d q4011-1 CHECK if BILLING AD DRESS <br />FACILITY NAME ( . AIN i N 01 1\1 1)1 IA' S <br />SITE ADDRESS /7 —) / <br />-' L Street Number Direction <br />U_ n i 0)--) <br />Street Name <br />S 1-- , „5/--oc__K4-cp, <br />City Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) uiloo Street Number <br />iiiE \1\) 00 0 5 DR \\.1 E i\Rit-;(51 <br />Street Name <br />CITY <br />I) N JOSE STATE C A ZIP 951.--G <br />EXT. PHONE #1 <br />( t_16 Z) 34- -30, 8 Li <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />Stk 1\( AWN <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (..a R mt. d s Imo <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME (A LIE R mil , fillS9 E S PHONE # <br />(U) "cA6--N 3 t-fxT <br />HOME or MAILING ADDRESS <br />WO AI .0 1 I 1 11\JE FAX # ( ) <br />CITY A 10 clo SE STATE CA zu. q o f 3 6 <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 SIGNATUR-- <br />PROPERTY / BUSINESS OWNER.121. OPERATOR / MANAGER Er OTHER AUTHORIZED AGENT 0 <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 :s <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 'Ori C°11 -5--(A/ t 4a-1 (3° PAYMENT <br />COMMENTS: <br />RECEIVED <br />NOV 1 8 2°16 <br />SAN JOAQUIN COUNTY <br />ENV1ROMENTAL <br />ACCEPTED BY: ..e.ci---61 EMPLOYEE #: i lEjkLII <br />DEPARTMENT <br />_/0 DATE : l <br />ASSIGNED TO: 13 65 /01 EMPLOYEE #: DATE: ii_ix _lie <br />Date Service Completed (if already completed): SERVICE CODE: 0 f PIE: lle,o c; <br />Fee Amount: i -•• — Amount Paid t 3 ci _ Payment Date / ( .... L cg-- ( ‘ <br />Payment TypeCc, c, Z_\ Invoice # Check # Received By: g....<., <br />EHD 48-02-025 <br />SR FORM (Golderod) <br />REVISED 11/17/2003 <br />DATE: i h / • 2 6 /,6' <br />pf,160 EA*
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