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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P (Z D 514-715 <br /> Type of Business or Property FACILITY ID# ERACEQREQUEST# <br /> Small Takeout Bakery F4 �(v-15-7 943 oq <br /> OWNER/OPERATOR �� __����uu <br /> KTKCo- Katie Bertilacchi CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Crumbl Cookie <br /> SITE ADDRESS 864W Benjamin Holt Drive Stockton 95207 <br /> Street Number DlreoNon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3966 Glen Abby Circle <br /> Street Number Street Name <br /> CITY Stockton STATE CA Zip 95219 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (209 ) 603-5583 09741060 <br /> PRUNER E% . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Staley Wellnitz CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E . <br /> Commercial Architecture 209 571-8158 <br /> HOME or MAILING ADDRESS FAx# <br /> 61614th Street ( ) <br /> CITY Modesto STATE CA Zip 95354 <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: ������� DATE: June 2, 2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICAAT iS 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 environmenta site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atme it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: Plan review <br /> COMMENTS: mileL /_O� SqN J ??0�I <br /> AQJJJJV <br /> JcheCk �mmercial aroll . com Heq THO�R Mt <br /> P!a✓ <br /> Nr <br /> ACCEPTED BY: Vida) Pedraza EMPLOYEE#: 6213 DATE: 6.2-21 <br /> ASSIGNED TO: Maribel FlohrsClltitZ EMPLOYEE#: 3361 DATE: 6-2-21 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P IE: 1601 <br /> Fee Amount: 456 Amount Pai � O Payment Date z Z <br /> Payment TypeInvoice# Check# Rece' ed By: <br /> EHD 48-02-025 Payment confirmation# 126282170 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />