WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CILITY ID # SERVICE REQUEST # Restaurant I�f' sill V qW 4 Kadeanne Llnhares OWNER i OPERATOR Golden Gate Bell LLC CHECK It BILLING ADDRESS FACILITY NAME Taco Bell s 3� SITEADDRESS 915 STRACY BLVD P I E: 1601 TRACY 456 Street Number Direction Street Name ZZ city Zi Cotle HOME or MAILING ADDRESS (If Different from Site Address) 3120 1 Invoice # S. DURANGO DRIVE Street Number Street Name CITY LAS VEGAS STATE NV ZIP 89117 PHONE#1 En. APN # LAND USE APPLICATION At ( 602) 714-3099 242-020-250 PHONE#2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Golden Gate Bell LLC CHECK If BILLING ADDRESS BUSINESS NAMETaco Bell EMPLOYEE#: 6213 PHONE# Ex . 714-3099 HOME Or MAILING ADDRESS 3120 S. DURANGO DRIVE Kadeanne Llnhares FAx# CITY LAS VEGAS STATE NV ZIP 89117 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. APPLICANT'S SIGNATURE: e e H*" DATE: 3/21/22 PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHERAUTRORI DAGENT® Architect If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre 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 environmentaVsite 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. paw TYPE OF SERVICE REQUESTED: Plan Check COMMENTS: Environmental Health RAR ?1 ?0z? ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 3-21-22 ASSIGNED TO: Kadeanne Llnhares EMPLOYEE #: 4559 DATE: 3-21-22 Date Service Completed (if already completed): SERVICE CODE: 523 P I E: 1601 Fee Amount: 456 Amount Pa i /-�.D� Payment Date ZZ Payment Type I %I q 14- 1 Invoice # ICheck# /�(� j{'¢,��}/ 2 Received By: EHD 48-02-025 payment confiramtion 140845063 SR FORM (Golden Rod) REVISED 11/17/2003