Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Food demonstrations/samples FACILITY ID # ERVICE`R�EQUEST # <br />OWNER / OPERATOR x L�CJ <br />Club Demonstration Services Inc. v <br />FACILITY NAME CHECK If BILLINGADDR=SS <br />Club Demonstration Services Inc <br />SITE ADDRESS <br />2440 <br />St eet Nu, <br />HOME or MAILING ADDRESS <br />Cm <br />Irvine <br />PHONE #1 <br />( 940 ) 295 7135 <br />PHONE#2 NIA <br />(If Different from Site Address) <br />SITE. <br />APN # <br />Daniels St <br />Manteca I 95337 <br />15310 Barranca Parkway- Suite 100 <br />deet Number <br />STATE <br />CA <br />ZIP <br />92618 <br />N/A LAND USE APPLICATION # <br />N/A <br />CONTRACTOR / SERVICE <br />REQUESTOR Club Demonstration Services Inc. <br />BUSINESS NAME Club Demonstration Services Inc. <br />BOS DISTRICT N/A <br />UESTOR <br />CHECK <br />PHONE # <br />LOCATION CODE <br />N/A <br />HOME or MAILING ADDRESS 940 295 7135 <br />15310 Barranca Parkway- Suite 100 FAX# <br />Cm Irvine I I N/A <br />STATE CA ZIP 92618 <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: BYitiail� tel, Co%N 11 116e Coof-611go - DATE: 11/17/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAILTRORIZEDAGENTQ( Compliance Coordinator <br />/f APPLICANT is not the BILLING PAPP Proof of authorization to sign is required Tit(e <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. <br />TYP S <br />EOF ERVICERI:uutbihu; <br />RECE(yED <br />COMMENTS: <br />NOV 2 2 Y0l <br />Club demonstrations <br />services at costco. <br />'AN JOAQUIN CMAFM <br />ENVIRONMENTAL <br />HEALTH a....NENT <br />ACCEPTED BY: Vidal Pedraaz <br />EMPLOYEE#: 6213 <br />DATE: <br />11-19-21 <br />ASSIGNED TO: G1 iFallltl <br />g }r <br />EMPLOYEE#: 8788 <br />DATE: 11.10.21 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 061 <br />P I E: 1602 <br />Fee Amount: 152 Amount Paid <br />IS 2 Payment Date <br />It yy yb 24 <br />Payment Type JA, Invoice # <br />Check # <br />Receive By: <br />REVISED 111 �,f..- ,t �� v� T" Lb t 7Q SR FORM (Golden Rod) <br />REVISED 11/1712003 (/_y®Ip�,�;/I <br />f f2o"-1359 S <br />