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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Coffee Shop <br />FACILITY ID # <br />5 <br />BUSINESS NAME <br />Glassman Planning Associates <br />SERVICE REQUEST # <br />sohog3ga-�7 <br />OWNER/ OPERATOR <br />Starbucks <br />HOME or MAILING ADDRESS 1111 Sartori Ave <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Starbucks Coffee <br />CITY Torrance <br />STATE CA ZIP 90501 <br />SITE ADDRESS 569 <br />Street Number <br />Direction <br />Clover Rd <br />Street Name <br />Tracy, CA <br />city <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />ACCEPTED BY: <br />STATE ZIP <br />PHONE #1 Ex . <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EZ . <br />( ) <br />�`^ham s <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Taylor Conterno <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Glassman Planning Associates <br />COMMENTS: <br />PHONE # En. <br />310 1 7818250 5 <br />HOME or MAILING ADDRESS 1111 Sartori Ave <br />FA"# <br />CITY Torrance <br />STATE CA ZIP 90501 <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 />APPLICANT'S SIGNATURE:jpz/Y�Z �y,Z,yg <br />PROPERTY/ BUSINESS OWNER El OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT IN <br />DATE: 3/17/21 <br />IjAPPL1CANT is not the BILLING PARTY proof of authorization to sign is required <br />Agent for Starbucks <br />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 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. pA L� <br />TYPE OF SERVICE REQUESTED: ,s`b<V" Inc L�j (— <br />COMMENTS: <br />Ptct-✓� T t %" Ca�-,V (LI V t <br />,tA�C <br />�ry/( �O <br />SqN✓ /�� <br />NFq�N%ROU/N <br />TN <br />pFpgRT <br />M <br />ACCEPTED BY: <br />Cl.CY✓K-C 5, <br />EMPLOYEE <br />DATE: -3 —� 2 - <br />ASSIGNED TO: <br />�`^ham s <br />EMPLOYEE <br />DATE: '6,_I� �2t <br />Date Service Completed (if already completed): <br />SERVICE CODE: S - <br />P t E:/_..� <br />wV <br />Fee Amount:1 <br />Amount Pai <br />1 <br />� t�V <br />Payment Date52 <br />Payment Type <br />�� <br />Invoice # <br />Check # '�� <br />, <br />Receiv d By:127) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 dI ID 015239513 <br />