WORK PLANS - Laserfiche WebLink

Home Browse Search

DocuSign Envelope ID: D39739F4-B197-479F-B72A-AD8E23A234F8 JAN JILJACJUIN l..C.)UN I r cNVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Retail FACILITY ID # SERVICE REQUEST # S R. 0 0 ? 3- CO S 1 OWNER/OPERATOR CHECK if BILLING ADDRESS 1+1 Five Below, Inc. FACILITY NAME Five Below, Inc. SITE ADDRESS 2350 Street Number W Direction Kettleman Lane Suite 130 Street Name Lodi, California City 95242 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 251 Attn: Business License Street Number Little Falls Dr Street Name CITY STATE ZIP Wilmington DE 19808 PHONE #1 Ex-r. ( 215 ) 546-7909 APN # LAND USE APPLICATION # PHONE #2 Err. ( ) EMAIL business.licensing@fivebelow.com BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # ( ) Ex-r. HOME or MAILING ADDRESS FAX # ( ) CITY STATE ZIP EMAIL 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, STATE and FEDERAL laws. p--DocuSigned by: APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER 0 %--oPtirafferoimANAGER OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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. TYPE OF SERVICE REQUESTED: iillg.- ,...," IV/N, ''''ZiVE6 COMMENTS: FEB n , " I 2024 SAN Jo , EljNY48LjiN CO ALTH r-, NMEN-r-UNTY L.) p4 po s, J AL ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 2-1-24 ASSIGNED TO: Francisco Ruiz EMPLOYEE #: 9838 DATE: 2-1-24 Date Service Completed (if already completed): SERVICE CODE: 523 P / E: 1601 Fee Amount: 486 Amount Paid c Lit Ro. op Payment Date 2/I V/- Payment Type ej<, li Invoice # Check # 0/Cy3/05-7.27 "?)--di Recei ed By: 17 ,5s7o_OF END 48-02-025 03/22/23 SR FORM (Golden Rod) DATE: 1/31/2024 Title