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Page 1 o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Service - Bakery Cafe : :1 r----- N09 f5 S <br /> OWNER/OPERATOR <br /> Winpin 85 Investment LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME 85c Bakery Cafe <br /> SITEADDRESS 87f West Benjamin Holt Drive Stockton CA_ 95207 <br /> SUael Number 1 Direction I Str..t Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1415 Moonstone Street <br /> Street Number Street Name <br /> CITY Brea STATE CA ZIP 92821 <br /> PHONE#1 Eu. APNN LAND USE APPLICATION# <br /> (949)500-7132 097-41-070 <br /> PHONE#2 Ext• SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Larry Wang CHECK If BILLING ADDRESS <br /> BUSINESS NAMETectonic Builders Corporation PHONE# EXT. <br /> P (408)216-0804 <br /> HOME Or MAILING ADDRESS 10118 Bandley Drive FAX# <br /> CITY Cupertino STATE CA ziP 95014 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 /> 1 also certify that I have prepared this application and that the worlr to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and f DEL laws. <br /> APPLICANT'S SIGNATURE: DATE: �h=f� <br /> PROPERTY/BUSINESS OWNERO OPERATOR/ ANAGE O OTHER AUTHORIZED AGENT® Architect <br /> {J•APPLTCINT is not the BiLmNG PA proo 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. 1 I- ENT <br /> TYPE OF SERVICE REQUESTED: Health Permit for Food Service CV f-'(✓L REG IVED <br /> COMMENTS: Tenant Improvement for a bakery coffee shop consists Of kitchen, bakery display and gift <br /> tables. NOV 0 2018 <br /> SAN JOAQU N COUNTY <br /> ENVIRON ENTAL <br /> HEALTH DEI RTMENT <br /> ACCEPTED BY: ln1""t f e EMPLOYEEM DATE: — (6 <br /> AssIGNEDTO: 1l{ EMPLOYEE#; DATE: 1_9_ I r <br /> Date Service Completed (if already completed): SERVICE CODE: Z3 P/ : /('.6 / <br /> Fee Amount: fk�(p , Amount Paid S _ Payment Date <br /> Payment Type 1,5 1\7 Invoice# CAe&# Yj CC L-) I Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117r2003 <br /> out:blank 11/9/20 <br />