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COMPLIANCE INFO_2021
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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LOUISE
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1231
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1600 - Food Program
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PR0535653
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
1/12/2022 1:02:50 PM
Creation date
3/4/2021 7:34:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0535653
PE
1623
FACILITY_ID
FA0020557
FACILITY_NAME
PAPA NINO'S PIZZA
STREET_NUMBER
1231
Direction
E
STREET_NAME
LOUISE
STREET_TYPE
AVE
City
MANTECA
Zip
95336
APN
19650004
CURRENT_STATUS
01
SITE_LOCATION
1231 E LOUISE AVE
P_LOCATION
04
P_DISTRICT
003
QC Status
Approved
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SJGOV\jcastaneda
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EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> REQUEST# <br /> TYPe of Business or Property FACILITY ID# SERVICE <br /> OWNER OPERATOR CHECK ff BILLINN <br /> 11 <br /> �aL•12 lel 0b,C <br /> FACILITY NAME <br /> ou <br /> cic �iz-zd <br /> SITE ADORE fIl,OlS `�j <br /> �676-33(o�53, <br /> 3to <br /> Fqq- <br /> � kac� WsSter/ ✓6Number D eNa <br /> HOME or MAIUNG ADDRESS (U DNremnt from Sim Address) I Y7qI m CD)C-� <br /> Street Number <br /> Cm Lem STA LP <br /> PHONE#1 E". APN N LAND USE APPLICATION# J <br /> (C)m H%3 -� <br /> PHONE#P En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR(a-'eL Via lICL CHECKit SIWNG ADD <br /> BUSINESS NAME/�n.✓'�� /�� 'Ja �PC k LI1) PH � � <br /> Ho or MAILING ADDRESS Y� V FAX# <br /> / 7 7 rr7 S TI-f c 1 <br /> CITY • STATE �-y ZJP <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 applicati and a wor o be performed will be done in accordance with all Sew JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and J <br /> APPLICANT'S SIGNATURE: DATE: to <br /> PROPERTY/BUSINESS OWNEk OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLLCANTT✓///Tis���notthe BmLu✓GPARTY proof ofauthorizadon 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available i' aI jhe same time it is <br /> provided to me or my representative. r f t YM <br /> TYPE OF SERVICE REQUESTED: VF,o <br /> COMMENTS; IVUV <br /> 4 20?1 <br /> RON <br /> 106 41�N74t <br /> ACCEPTED BY: EMPLOYEE M �]3 DATE: I 1 7 1 <br /> ASSIGNED TO: r L EMPLOYEE#: �/ DATE: �1 dl <br /> Date Service Completed (If already completed): SERVICECODE: ' / P)E• // <br /> Fee Amount: 52"O Amount Paid /sa ( � Payment Date �l,J �l�L <br /> Payment Type Invoice# Check# / g/ -/ <br /> p\ U Received By: <br /> "S EHD 48-02-025 <br /> REVISED 11117/200310 r% ���� SR FORM(Golden Rod) <br />
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