Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A <br />FACILITY ID # <br />BUSINESS NAME C. C. Planning & Permitting Services <br />SERVICE REQUEST <br />PHONE# <br />559 <br />EX . <br />720-8638 <br />HOME or MAILING ADDRESS 3275 N Dante Ave. <br />ASSIGNED TO: Gehane Pahmy <br />()# <br />Quick Serve Restaurant <br />CITY Fresno <br />STATE CA <br />ZIP93722 <br />D <br />OWNER / OPERATOR <br />456 <br />CHECK If BILLING ADDRESS El <br />Ghai Management Services. <br />Payment Date YIZI�121 <br />Payment Type <br />FACILITY NAME <br />Invoice # <br />Check # I $ <br />Burger King <br />SITEADDRESS 744 <br />North <br />Jack Tone Road <br />I <br />Ripon, CA <br />95366 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 25 <br />E. Airway Blvd. <br />Street Number <br />Street He <br />CITY Livermore <br />STATE CA <br />ZIP 94551 <br />PHONE #1 En. <br />APN # <br />LAND USE APPUcATON # <br />( 510 ) 573-5905 <br />250-250-14 & 15 <br />D19-0012 <br />PHONE #2 EXi. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Charlie Brown, Owner <br />A <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME C. C. Planning & Permitting Services <br />% <br />C�c 'E7/ v'§6 <br />Mq y 2 Fp <br />3 EN AQUI 6 ZO?I <br />hFy�Ty Do/vMEC�O„ONT <br />PHONE# <br />559 <br />EX . <br />720-8638 <br />HOME or MAILING ADDRESS 3275 N Dante Ave. <br />ASSIGNED TO: Gehane Pahmy <br />FAx# <br />DATE: 5-26-21 <br />CITY Fresno <br />STATE CA <br />ZIP93722 <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 a aws. <br />,'rpp <br />APPLICANT'S SIGNATURE: DATE: 05/17/2021 <br />PROPERTY/ 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite 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 />TYPE OF SERVICE REQUESTED: Plan review <br />A <br />COMMENTS: <br />% <br />C�c 'E7/ v'§6 <br />Mq y 2 Fp <br />3 EN AQUI 6 ZO?I <br />hFy�Ty Do/vMEC�O„ONT <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE <br />ASSIGNED TO: Gehane Pahmy <br />EMPLOYEE #: 8788 <br />DATE: 5-26-21 <br />DateServiceCompleted (if already completed): <br />SERVICECODE: 523 <br />PIE: 1601 <br />Fee Amount: <br />456 <br />Amount Paid <br />TJlp <br />Payment Date YIZI�121 <br />Payment Type <br />i <br />Invoice # <br />Check # I $ <br />Received By: <br />9— <br />EHD 48-02-025 Payment confirmation # 125887234 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />