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Page <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL I-IEALTI4 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Service - Bakery Cafec�g'C>� <br /> OWNER/OPERATOR <br /> Winpin 85 Investment LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME - 85c Bakery Cafe <br /> SITE ADDRESS 87,V) West Benjamin Holt Drive Stockton CA 95207 <br /> Street Number Direction I Street Name City I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1415 Moonstone Street <br /> Street Number Street Name <br /> CITY Brea STATE CA ZIP 92821 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (949)500-7132 097-41-070 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Larry Wang CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> Tectonic Builders Corporation 408 216-0804 <br /> HOME or MAILING ADDRESS 10118 Bandley Drive FAx# <br /> ( 1 <br /> CITY Cupertino STATE CA ZIP 95014 <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 fonn. <br /> I also certify that I have prepared this application and that the wor- to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and � .DER L laws. <br /> APPLICANT'S SIGNATURE: ` DATE,: 1 I <br /> p� <br /> T <br /> PROPERTY/BUSINESSO\\'NRR❑ OPERATOR/. %NAGF.I ❑ 0I'll ERAI!THORI7.F.DAGFAT 0 Architect <br /> If;I PPLIG1,vT is nat the RILi.I.�'G I':u l I' proof of authorization to sign is required TiNe <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 HEALTIi 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: Health Permit for Food Service C�neCle. 9 , <br /> COMMENTS: Tenant Improwament for a akery coffee shop consists of kitchen, bakery display and gift <br /> table ; �,r,�u i v 0 9 2N <br /> .— SAN JOAQU N COLIN <br /> ENVIRONMENTAL <br /> HEALTH DE ARTME <br /> ACCEPTED BY: (+' v^r S EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1'( V �> � EMPLOYEE#: DATE: /_��_ id' <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 : / <br /> Fee Amount: 4-S tD r Amount Paid -t� ��— Payment Date L( <br /> Payment Type ), Invoice# Chedk# Ct Receivec(By: <br /> EHD 48-02-025 �� C1 ON G Q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />