Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />Restaurant <br />7010 <br />SAN JOA QUI <br />HEALTH p PAR Z Nry <br />PHONE# <br />OWNER / OPERATOR <br />EMPLOYEE#: �I <br />L8M Tugboats, LLC C/O Scott LOvotti <br />CHECK if BILLING AOORESs <br />FACILITY NAME TUGBOATS <br />HOME Or MNLING ADDRESS 2216 Stewart St <br />SITE ADDRESS 946 <br />N <br />Yosemite St <br />SERVICECODE: �j '' <br />Stockton <br />95203 <br />s <br />CITY S,a,,,a„ <br />STATE CA <br />ZIP 95205 <br />Payment Date <br />9/72 <br />HOME or MAILING ADDRESS (It Different from Site Address) 2216 <br />Invoice# <br />Stewart St <br />street Number <br />Received By: <br />Cm <br />STATECA ZIP 95205 <br />Stockton <br />PHONE #1 Ekr <br />APN # <br />LANn Use APPLICATION # <br />( 209 1 649-3736 <br />PHONE#2 Ei. <br />( 1 <br />BOS DISTRICT <br />LOCATIONCODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ScottLovottl <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Lcvotti Inc <br />7010 <br />SAN JOA QUI <br />HEALTH p PAR Z Nry <br />PHONE# <br />Exr. <br />EMPLOYEE#: �I <br />DATE: "1 � <br />209) <br />931-2100 <br />HOME Or MNLING ADDRESS 2216 Stewart St <br />DATE: 2J '1 /� <br />oDCh�/ <br />JP <br />Fax <br />SERVICECODE: �j '' <br />1205) <br />941-2121 <br />CITY S,a,,,a„ <br />STATE CA <br />ZIP 95205 <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 1 have prepared this applic (on and lha a voik to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST . al ED aws. — <br />APPLICANT'S SIGNATURE: / DATE: 03/09/2020 <br />PROPERTY! BIISINFSSOWNER® OPERATOR/ MANAGER ❑ OTHER AtrrnORIZED AGENT <br />IfAPPCJCANT is not the BILLING PARTproof of authorization to sign is required Tide <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 environm�eF�.t+a sue assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available ancLll �a�j'Lirye,ll is <br />provided to me or my representative. Jeer. r 1 — <br />TYPE OF SERVICE REQUESTED: <br />COMMEM. <br />7010 <br />SAN JOA QUI <br />HEALTH p PAR Z Nry <br />ACCEPTED BY: <br />EMPLOYEE#: �I <br />DATE: "1 � <br />ASSIGNED TO:S�ey�/ J A n <br />V" <br />EMPLOYEE #: t O / <br />DATE: 2J '1 /� <br />oDCh�/ <br />JP <br />Date Service COmple d (if already completed): <br />SERVICECODE: �j '' <br />E: <br />Fee Amount: 5-�, <br />Amount Pal <br />TS; ,0 0 <br />Payment Date <br />9/72 <br />Payment Type - <br />Invoice# <br />Check# /�� � - !✓ <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />