Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />grab and go bakery, no seats, no alcohol <br />FACILITY ID # <br />- boa--1 -7 \ SERVICE REQUEST # <br />5Rooscoa4 q- <br />OWNER / OPERATOR <br />CHECK if Manjural Alam BILLING ADDRESS <br />FACILI%IAME , etzel s Pretzels <br />SITE ADDRESS <br />4950 suite 114 Street Number Direction <br />Pacific Ave <br />Street Name <br />Stockton <br />City <br />CA <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />5452 E Pitt Ave Street Number Street Name <br />CITY Fresno <br />STATE ZIP <br />CA 93272 <br />PHONE #1 Exr. <br />( 55 341 8394 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Manjural Alam CHECK if BILLING ADDRESS X <br />BUSINESS NAME <br />Wetzel's Pretzels <br />PHONE# <br />( 559 ) 341 8394 <br />EXT. <br />HOME or MAILING ADDRESS <br />5452 E Pitt Ave <br />FAX# <br />t ) <br />CITY Fresno STtTAE ZIP 93272 <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: Wail.-U&aI 42M1, DATE: 1/11/23 <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTIIER AUTHORIZED AGENT 0 <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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa <br />r <br />kiiine it is <br />provided to me or my representative. r‘!OF <br />ty, <br />TYPE OF SERVICE REQUESTED: <br /> <br />VI ixim CommENTs: 1 , <br />Sgill JO ( 202 <br />1.4 6-1** 4 00 <br />, , <br />ACCEPTED BY: LL b---- <br />EMPLOYEE #: q (c---/ s DATE: 3 <br />ASSIGNED TO: L ( ( c R_ EMPLOYEE it: Cal (S"' DATE: /4„3/)_3 <br />Date Service Comple d (if already completed): _ SERVICE CODE: S c •7k '3 P / Ex .,2(-)/ <br />Fee Amount: LA - , Amount Paid ) , Payment Date 2. 2_3 ) <br />Payment Type <br />i <br />Invoice # Check # 6,(Y-0 Receiv d By: <br />dip <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003