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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 Coffee S�,06-7 96 99 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> BB Holdings CA LLC Dutch Mafia Inc., dba Dutch Brothers Coffee <br /> FACILITY NAME <br /> Dutch Brothers Coliee <br /> SITE ADDRESS 1 Hammer Lane Stockton 95210 <br /> 1505 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 110 SW 4th Street Street Number Street Name <br /> CITY STATE ZIP <br /> Grant Pass OR 97526 <br /> PHONE#1 Ex r. APN# LAND USE APPLICATION# <br /> ( 541-237-4430 650 CO-7 <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> ( ) 0 L_ G � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Heidi CHECK If BILLING ADDRESS <br /> BUSINES NAM PHONE# ExT. <br /> Acute onslin ,Inc 925 818-4132 <br /> HOME or MAILING ADDRESS E-Mail: <br /> 29 Orinda Way#1267 Heidi@Acute-Consultiny.com <br /> Cffrinda STATE CA ZIP 94563 <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 tha�the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,j�3' FEAL laws. <br /> APPLICANT'S SIGNATURE: �ER� DATE: 9-21-15 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ Permit - Consultant <br /> If APPLICANTis 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. L <br /> TYPE OF SERVICE REQUESTED: 7 <br /> COMMENTS: <br /> Tenant Improvement for new drive thru Dutch Brothers Coffee with no seating or food. Sep <br /> C'L.�>'uyl 12 Q�,G GC^ -� L�-c t G�r 4--e '9 <br /> QUtH ?�1 <br /> ��— � .�FpMFH��N <br /> ACCEPTED BY: EMPLOYEE#: DATE: �•2" / T <br /> ASSIGNED TO: EMPLOYEE#: DATE: 'L _ <br /> Date Service Completed (if already Completed): SERVICE CODE: P/I E. (6 O <br /> Fee Amount: ��— Amount Paidfib'! l) Payment Date 9 2 <br /> Payment Type C!� Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />