WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Mobile Food Facility FACILITY ID # r\ e\J...) SERVICE REQUEST # sevo 61 49 2- OWNER / OPERATOR Mariejo Bermudez — CHECK if BILLING ADDRESS FACILITY NAME Casa Pinoy — ___C<--_)3 ck —k- (c.xA \ e r SITE ADDRESS 15932 Street Number Direction Crescent Park Cir Street Name Lathrop City 95330 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 15932 Street Number Crescent Park Cir. Street Name CITY STATE ZIP Lahrop CA 95330 PHONE #1 EXT. ( 408 ) 772-3372 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL info.casapinoy@gmail.com BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mariejo Bermudez CHECK if BILLING ADDRESS BUSINESS NAME Casa Pinoy PHONE # ( 408 ) 772_3372 Err. HOME or MAILING ADDRESS 15932 Crescent Park Cir FAX # ( ) CITY Lathrop STATE CA ZIP 95330 EMAIL info.casapinoy@gmail.com 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 certify 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, ST and FEDEFAL laws. APPLICANT'S SIGNATURE: DATE: 11/30/2023 PROPERTY / BUSINESS OWNER 12 OPERATOR /1IANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT Is not the BILLING PARTY proof of authorization to sign is required 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. m. r‘i ligeNT TYPE OF SERVICE REQUESTED: rieCEIVED COMMENTS: electronic DEC 0 4 2023 SAN JOAQUIN COUNTY HEALTH HEALTH DEPARTMENT ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 12 -1-23 ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 12 -1-23 Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 Fee Amount: 486 Amount Paid fi V 3-4 ,-- Payment Date Received By:N----7 Payment Type V / 6 fi Invoice # "Kraj# / 'q-21--5-"76 4, END 48-02-025 SR FORM (Golden Rod) 03/22/23 PRoSt-i ool