My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
COMPLIANCE INFO_2023
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
D
>
DR MARTIN LUTHER KING JR
>
405
>
1600 - Food Program
>
PR0161142
>
COMPLIANCE INFO_2023
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
12/28/2023 9:24:50 AM
Creation date
7/21/2023 1:43:13 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2023
RECORD_ID
PR0161142
PE
1624
FACILITY_ID
FA0002118
FACILITY_NAME
MARISCOS EL CHARRO
STREET_NUMBER
405
Direction
E
STREET_NAME
DR MARTIN LUTHER KING JR
STREET_TYPE
BLVD
City
STOCKTON
Zip
95206
APN
14726313
CURRENT_STATUS
01
SITE_LOCATION
405 E DR MARTIN LUTHER KING JR BLVD
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\ymoreno
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
4
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
Ilk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T-R 0002-ICS(� OD 1--y �K2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS [--10':5 <br /> '0� �- n/ • ,�!(C��'�"1 ll lil+T V`�✓ ��'\ �1 S Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 0 C,<\__Y\ <br /> C p Street Number Street Name <br /> CITY STATE ZIP <br /> qs <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (S5y) 1SS yAr�'� <br /> PHONE#2 Eur. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS AMC\E PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: `y` ��Vyut;VLji,, DATE: 1 / 3 <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or my <br /> representative. r (— <br /> TYPE OF SERVICE REQUESTED: 1 C I�VL`JLt -A"Cfvl t- �IV^ <br /> COMMENTS: V V 1a Y W`Q C..F� �' 'Y � 1016C ® �Ct' <br /> 1 0 <br /> O2E <br /> N �ROEOEALH NM �NryDEpgRAL <br /> ACCEPTED BY: I EMPLOYEE#: DATE: t7 I 23 <br /> ASSIGNED TO: C VVA- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: U L <br /> . u Fee Amount: , Amount Paid /� d� Payment Date ' 23 <br /> Payment Type - Invoice# Check# 12 2-S3 1 J OL) I <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />
The URL can be used to link to this page
Your browser does not support the video tag.