Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Juice bar <br />FACILITY ID # SERVICE REQUEST # <br />scz up g-R- 4 ,4 1 <br />OWNER / OPERATOR <br />Bans Group, Inc / Kash Ban CHECK if BILLING ADDRESS M <br />FACILITY NAME Juice it Up <br />SITE ADDRESS 1117 <br />Street Number <br />West <br />Direction <br />March Lane <br />Street Name <br />Stockton <br />City <br />CA <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Alejandra Zoquiapa CHECK if BILLING ADDRESS <br />BUSINESS NAME GWA Architecture Inc. PHONE # <br />( 626 ) 288-6898 <br />EXT. <br />HOME or MAILING ADDRESS <br />1000 Corporate Center Drive Suite 550 <br />FAX # <br />( 1 <br />Cr Monterey Park <br /> <br />STATE ZIPy CA 91754 <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: 4 A- Cate/44- DATE: 11/05/23 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 121 Job Captain <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 environmen 1/site assessment <br />rm infoation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a iitmee it is <br />414 <br />provided to me or my representative. P Ni- <br />-f TYPE OF SERVICE REQUESTED: e 4- NOV 1 p 1„023 COMMENTS: CZYA U <br />\NO . SAA/ Jo <br />\fe,010 l'' <br />14 iNilf/i1C)tniV rs ''EAL ONm -01m - 7-1.1 DEP4AITAL 7.- <br />mE-Nr. <br />ACCEPTED BY: EMPLOYEE #: DATE: t 1 1(4 <br />ASSIGNED TO: (-2),‘ ick\AL EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: C 7.3 PIE: (lc() f <br />Fee Amount: •-"7-2....C1 . <br />. <br />--- Amount Pai Payment Date :723 <br />Payment Type 1/1 SeA_, Invoice # Check # /7/ 7 Kg2./-? Receivec By: MD------ <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003 Pi22sDoNS