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Environmental Health - Public
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EHD Program Facility Records by Street Name
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U
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UNION
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1717
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1600 - Food Program
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PR0547125
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Entry Properties
Last modified
10/28/2021 11:52:06 AM
Creation date
8/26/2021 3:59:54 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
WORK PLANS
RECORD_ID
PR0547125
PE
1635
FACILITY_ID
FA0026733
FACILITY_NAME
EL RANCHO #4UF8394
STREET_NUMBER
1717
Direction
S
STREET_NAME
UNION
STREET_TYPE
ST
City
STOCKTON
Zip
95206
APN
16904012
CURRENT_STATUS
01
SITE_LOCATION
1717 S UNION ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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SJGOV\jcastaneda
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EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Si�DO 9 33 y°I <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 7 0 Q� ,�C �j \ tq O�e 5 a <br /> Street Number Direction Str¢et Name J I ems. Cit %Zi Coda <br /> OME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr• APN# LAND USE APPLICATION# <br /> ( go <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L . r Y-'J F,, u e I,-,Q cA CHECK If BILLING ADDRESS <br /> BUSINESS NAMES+.. PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> Tn o 01 e S ( ) <br /> CITY L STATE L 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 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: r b—l q E,/ !) ver o G DATE: C7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT i.Y not the B/LLrNGPAKTP 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. w <br /> TYPE OF SERVICE REQUESTED: ADD Qlh CL'IQ , AYM <br /> COMMENTS: xJCE�/ED <br /> "" 0 3 2021 <br /> y��&WdOAQU1N UN <br /> DO pARTTAL TM <br /> ACCEPTED BY: - Ihll n EMPLOYEE#: DATE: <br /> ASSIGNED TO: V v!`e tl ll� EMPLOYEE#: DATE: <br /> Date Service Completed (if`already completed): SERVICE CODE: 'I, PIE: <br /> Fee Amount: Amount Pai 14S-6- Payment Date -31-512— <br /> Payment <br /> 3 ZPayment Type Invoice# Check# Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />
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