Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Coffee Shop (Food establishment - 16.24) <br />FACILITY ID # <br />(\CA)- <br />SERVICE REQUEST # <br />5 g(t)e) B(0 Elo1 <br />OWNER / OPERATOR <br />William Spragge CHECK if BILLING ADDRESS <br />FACILITY NAME Central Coffee Company <br />SITE ADDRESS 624 <br />Street Number <br />N <br />Direction <br />Central Ave. <br />Street Name <br />Tracy <br />City <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 740 <br />Street Number <br />Rockport Ct. <br />Street Name <br />CITY STATE ZIP Tracy CA 95377 <br />PHONE #1 EXT. <br />(925)399-1717 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( 209) 831-2727 <br />EMAIL <br />sip@centralcoffeetracy.com <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CMR Builder <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />CMR Builder <br />PHONE # Exr. <br />(209 )321-5487 <br />HOME or MAILING ADDRESS <br />252 W Larch Rd. <br />FAX # <br />( 1 <br />CITY Tracy STATE CA ZIP 95304 EMAIL norcalplumbing@hotmail.com <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 />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: 6{A/lemi., D ATE: 6/24/2023 <br /> <br />PROPERTY / BUSINESS OWNER 12 OPERATOR MANAGER ti OTHER AUTHORIZED AGENT 0 <br />/f APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />Title <br />n to the address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infor <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid <br />representative. <br />TYPE OF SERVICE REQUESTED: \---0 (-1/4. 0 \ cc.(-N C._ \r"--Q-c- k J&N - 'V$ .4 <br />84 , 2 <br />COMMENTS: wa, 6 <br />202a <br />17 xli vi-,(,v/O`',1,416v c <br />' 1),041479441/2-1, <br />"747. <br />ACCEPTED BY: LA r‘ VA,C4.:( e_.(.. EMPLOYEE #: c4 5- 8 DATE: <br />ASSIGNED TO: L,‘,` (...\ \i\cNi,- .p s EMPLOYEE #: LA S (b ci ., DATE: (43 _ 7 (Q- ?3 <br />Date Service Completed (if already completed): SERVICE CODE: P/E:160‘ <br />Fee Amount: Vk koitiS -- Amount Paid Lk b _ Payment Date c_) - 2, _ 2 <br />Payment Type c c Invoice # Check # /64332444v Received By: <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23