COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property, FACILITY ID# SERVICER^EQUEST# Food demonstrations/samples �t cz-�l L4 OWNER/OPERATOR CHECK If BILLING ADDRESS❑ Club Demonstration Services Inc. FACIUmNAME Club Demonstration Services Inc. SITEADDRESS 1616 E Hammer Ln Stockton 95210 Street Number Direetian L Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 15310 Barranca Parkway-Suite 100 Street Number Street Na e CITY Irvine STATE CA ZIP 92618 PHONE#1 Exr. APN# N/A LAND USE APPLICATION# N/A 1 940) 295 7135 PHONE#2 N/A EXT. BIDS DISTRICT N/A LOCATION CODE ( ) N/A CONTRACTOR/ SERVICE REQUESTOR REQ'UESTOR Club Demonstration Services Inc. CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Elm. Club Demonstration Services Inc. 940 2957135 HOME or MAILING ADDRESS 15310 Barranca Parkway-Suite 100 FAX# ) N/A CITY I. Irvine STATE CA ZIP 92618 BH LING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackpowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ��JEtG{N�1 RPk,, COWJ[ailC6 CDOdjil Ml— DATE: 11/17/2021 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTaoRizEDAGENT compliance Coordinator YAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: RECE.NEU COM I NTS: NOV T 2021 Club demonstrations services at costco. SAN JOAQUIN COUNTY ENVIRONMENTAL 1l HEALTH DEPARTMENT T, I1 ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 11-19-21 ASSIGNEDTO: DariaAfonskata EMPLOYEEM 9825 DATE: 11-19-21 Date Service Completed (if already completed): SERVICECODE: 061 PIE: 1602 Fee Amount: 152 Amount Paid 1 SL ! Payment Date i6 Z� Payment Type `� Invoice# Check# / Received By: EHD 48-02-025 Payment confirmation# 134929090 Lt / 21j 2,/ SR FORM(Golden Rod) REVISED 11/17/2003 / Pia X31