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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 Shop-No Seating <br /> OWNER/OPERATOR <br /> J&W Lau Investments Prop LLC. CHECK It BILLING ADDRESS <br /> FACILITY NAME Dutch Bros Coffee-CA-0804 <br /> SITE ADDRESS 1105 W Yosemite Ave Manteca, CA 95337 <br /> Street Number Directlan I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PO Box 1098 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Atwater CA 95301 <br /> PHONE#1 Ezr• APN# LAND USE APPLICATION# <br /> ( ) 217-600-400 <br /> PHONE#2 Ex, BOIS DISTRICT LOCATON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Omar Garzon, Project Manager, omarg@gnicharch.com CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Gnich Architecture Studio PHONE# 971-346-2525 En. <br /> HOME or MAILING ADDRESS 1001 SE Sandy Blvd, Suite 100 FAX# <br /> C1TY Portland STATE OR ZIP 97214 <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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> Digitally signed by Omar G <br /> APPLICANT'S SIGNATURE: Date:2020.05.0118:38:51 DATE: 05/01/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager <br /> IfAPPLICANT is Hol the BiLLLvc PARTY proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ilit�@tne time it is <br /> provided to me or my representative. 1Y'M1, <br /> TYPE OF SERVICE REQUESTED: �(� /y <br /> COMMENTS: UV I MAY U <br /> 4 20 <br /> SAN-JOA <br /> QUI <br /> HEALTH DE ARM NTY <br /> ACCEPTED BY: G6GV-r%4 ZS C O EMPLOYEE#: DATE: <br /> ASSIGNED TO: 7_ EMPLOYEE III: DATE: �L <br /> Date Service Completed (if alre dy completed): SERMCE CODE: Sz3I PIE: I <br /> Fee Amount: c&-1 Amount Paid / .OD Payment Date ya <br /> Payment Type ,3A— I Invoice# Check# d8/g7 f p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />