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WORK PLANS
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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M
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MINER
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647
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1600 - Food Program
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PR0542450
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Entry Properties
Last modified
12/20/2021 8:46:03 AM
Creation date
12/20/2021 8:43:22 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
WORK PLANS
RECORD_ID
PR0542450
PE
1617
FACILITY_ID
FA0024396
FACILITY_NAME
MINER MARKET
STREET_NUMBER
647
STREET_NAME
MINER
STREET_TYPE
AVE
City
STOCKTON
Zip
95202
CURRENT_STATUS
01
SITE_LOCATION
647 MINER AVE
P_LOCATION
01
QC Status
Approved
Scanner
SJGOV\jcastaneda
Tags
EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REOUESTOR <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 />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: 1 DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ / <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as ent information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time I %y <br />p� or <br />my representative. �tl� <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: l <br />Date Service Complete (if already completed): <br />Fee Amount: I Cab Amount Paid <br />Payment Type (7 /� Invoice # <br />i <br />EHD 48-02-025 <br />07/17/08 <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />), O� I Payment Date <br />Check# /r) <br />SAN dOAQU--" <br />Ejvv/aIN C <br />E4L'-" PAR O1VMEMSN- <br />DATE: <br />-)/- / _i-7 <br />DATE: - / - / -�' <br />PIE: <br />f l 1 _" <br />Received By: <br />SR FORM (Golden Rod) <br />
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