Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Canteen @Amazon DCK1 <br />SERVICE RE LIEST # <br />BUSINESS NAME <br />PHONE # <br />Compass Group USA Inc dba Canteen <br />1 704 <br />DOST <br />OWNER / OPERATOR <br />FAX # <br />Compass Group USA Inc, 2400 Yorkmont Road, Attn: Licensing <br />Compass Group USA Inc <br />dba Canteen <br />CITY Charlotte STATE <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Canteen @ Amazon DCK1 <br />SITE ADDRESS <br />2403 <br />W <br />Louise Ave <br />Manteca <br />95337 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2400 <br />Yorkmont Road <br />Compass Group USA Inc. Attn: Licensing <br />street Number <br />street Name <br />CITY <br />STATE <br />ZIP <br />Charlotte <br />NC <br />28217 <br />PHONE #1 Es . <br />APN # <br />LAND USE APPLICATION # <br />( 704) 328-5521 <br />PHONE #LExt' <br />I I Nicole. Rollins com <br />ass-usa.com <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Canteen @Amazon DCK1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />Compass Group USA Inc dba Canteen <br />1 704 <br />328-5521 <br />HOME or MAILING ADDRESS <br />FAX # <br />Compass Group USA Inc, 2400 Yorkmont Road, Attn: Licensing <br />( 704) <br />295-5041 <br />CITY Charlotte STATE <br />NC <br />ZIP 28217 <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 SIGNATURE: N p I't'V— DATE: 9/10/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />IfAPPL/GWT 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 is <br />provided to me or my representative. PA tom_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS:. I cp <br />SfP 84 IV J 14 <br />U21 <br />h�Mi"'0 "NTYCr�qTg <br />,, <br />ACCEPTED BY: Vidal Pedraza EMPLOYEEM 6213 DATE: 9-14-21 <br />ASSIGNEDTO: GlgiFahmy EMPLOYEEM 8788 DATE: 9-14-21 <br />Date Service Completed (if already completed): I SERVICE CODE: 061 1 PIE: 1602 <br />Fee Amount: 152 1 Amount Paid /,<' nn I Payment Date 'r1JW 2t <br />Payment Type I/ I yy Invoice # Check # / �LPi c �y.7 I Received By: /_ I <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Payment Confirmation # 131495842 <br />f fo" 133Z <br />SR FORM (Golden Rod) <br />