SR0085572 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Medical SpaGrJ CHECK If BILLING ADDRES FACILITY ID # VA`A SERVICE REQUEST # a OWNER / OBE? TOR r. uis Melendez CHECK If BILLING ADDRESS FACILITY NAME Revive Me Aesth ACCEPTED BY: SITE ADDRESS 445 Street Number W Direction Beverly Place Street Name Tracy City 95376 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number #: 9 Street Name CITY STATE ZIP Date Service Completed (if already completed): PHONE #1 EXT, (209 )855-1463 SERVICE CODE: 041 APN # LAND USE APPLICATION # Paid 5 I PHONE #2 EXT. ( ) 2G �2 Payment Date164o Payment Type Invoice # BOS DISTRICT ReceivedBy: LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR L)r.LUIS Melendez CHECK If BILLING ADDRES BUSINESS NAME Revive Me Aesthetics VA`A PHONE# EXT. 209 855-1463 HOME or MAILING ADDRESS 445 W. Beverly Place FAX# CITY Tracy STATE CA zip 95376 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also cert ify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY/ BUSINESS �a DATE: OWNER OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IJ APPLICANT is not the BILLING PARTY, proof ojauthorization to sign is required 7/19/2022 Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. bk� TYPE OF SERVICE REQUESTED: C N "1 .. COMMENTS: Health inspection for Body Art Tattooing VA`A 8ANd� H EN y/RO U/N Co IJ �LTydFi�A�Nr�4� ri ACCEPTED BY: EMPLOYEE #: q DATE: 7420 t ASSIGNED TO:EMPLOYEE #: 9 DATE: 7/,71 /,1.7 Date Service Completed (if already completed): SERVICE CODE: 041 PIE: q r Fee Amount: gAmount Paid 5 I 2G �2 Payment Date164o Payment Type Invoice # lpq(pl I ReceivedBy: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003