Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Merchandiser SRO/V(P-,01 <br /> OWNER/OPERATOR <br /> Five Below Inc. CHECK if BILLING ADDRESS <br /> FACILITY NAME Five Below (1349) <br /> SITE ADDRESS 10644 TrinityParkway Y Stockton 95219 <br /> Street Number I Direction I me city21 Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) 701 <br /> Marktet Street, Suite 300 <br /> Street Number SVeet Name <br /> CITY Philadelphia STATE PA zip 19106 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (215546-7909 2784 <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( 1 3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <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 EN'vIRONMENTAL 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: S cz�i — �u e go.2eur, wm- , DATE: 06/03/2020 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Business License Coordinator <br /> If APP[/CANT is no!the BILLLNG 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: LAOA op q y <br /> COMMENTS: C/�/vt <br /> SA IV <br /> OgQUI <br /> NegLT,O pMENOUN <br /> ACCEPTED BY: 1/1 EMPLOYEE M DATE: /A T <br /> ASSIGNEDTO: s t I EMPLOYEE DATE: LY <br /> Date Service Completed (if already completed): SERVICE CODE: pit: <br /> I 02 <br /> Fee Amount: �' Amount Paid UD Payment Date <br /> Payment Type �'� Invoice# Check# /v y �� Received By: <br />' EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />