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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Coffee,Dutch Brothers CoffeeSr-d0-785g�1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Dutch Brothers Coffee -C rnat I r I ILI n✓1 CIA V 1'-5 d it4r_kI b rvS , 4oryl <br /> FACILITY NAME <br /> Dutch Brothers Coffee <br /> SITE ADDRESS <br /> S Center Street Stockton 95202 <br /> 121 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 110 SW 4th Street <br /> 110 Street Number Street Name <br /> CITY STATE ZIP <br /> Grants Pass OR 97526 <br /> PHONE#'I Err. APN# LAND USE APPLICATION# <br /> ( 541 ) 955-4700 <br /> PHONE#Z Exr BOS DISTRICT LOCATION CODE <br /> ( i4 I ) 6P (o U D 1� t-t3 n i7 .� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Heidi CHECK if BILLING ADDRESS <br /> PUSINESs NAME PHONE# ExT• <br /> Acute Consultin , Inc 925 818-4132 <br /> HOME or MAILING ADDRESS E-Mail: <br /> 29 Orinda Way#1267 Heidi@Acute-Consultinv,.com <br /> Cffrinda STATE CA ZIP 94563 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,] IFi' ERAL S. <br /> APPLICANT'S SIGNATURE: DATE: 1-2-18 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Permit - Consultant <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: <br /> COMMENTS: PAY 1E <br /> Tenant Improvement for new drive thru Dutch Brothers Coffee shop with no seating or food. RECEIV D <br /> / �`-�. () e7 t JAN 0 5 017 <br /> 0-e <br /> Ci lR. S SAN JOAOUIN C UN7Y <br /> 1 """RONMEN AL <br /> HEALTH DEPAR MENT <br /> ACCEPTED BY: v n"A—y-" EMPLOYEE M DATE' �/Q <br /> ASSIGNED TO: D VA_ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: —�2 PIE: <br /> (�Q <br /> Fee Amount: $Lf r (� Amount Paid $ Payment Date <br /> Payment Type c (,� Invoice# Check# 1 -2) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />