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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK IT BILLING ADDRESS® SERVICE REQUEST # Coffee Shop - No Seating PHONE 111 971-346-2525 Err. c J � OWNER/ OPERATOR CHECK If BILLING ADDRESS Dutch Bros LLC. dba Dutch Bros Coffee CITY FACILITY NAME ZIP 97214 Dutch Bros Coffee - CA -0807 Date Service Completed (if already completed): SITE ADDRESS 1220 SERVICE CODE: 'J2 Colony Road I PIE: f W D f Ripon, CA 95358 Street Number DI if Street Name Payment Type !moi City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Receive By: 110 SW 4th St. Street Number Street Name CITY STATE ZIP Grants Pass OR 97526 PHONE #1 Exr. APN # LAND USE APPLICATION # (541 9554700 261-600-13 PHONE #2 En. SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Omar Garzon, Project Manager, omarg@gnicharch.com g g@gnicharch.com CHECK IT BILLING ADDRESS® BUSINESS NAME Gnich Architecture Studio PHONE 111 971-346-2525 Err. HOME or MAILING ADDRESS 1001 BE Sandy Blvd, Suite 100 FAx# DATE: 21-1812,t CITY Portland STATE OR ZIP 97214 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. Digitally signed by Omar Garzon APPLICANT'S SIGNATURE: Date: 2021.01.191t34:ts-oboo• DATE: 01/20/2021 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager IJAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t�AT tpime it is PL - provided to me or my representative. l�C^^1I.: ' •71 TYPE OF SERVICE REQUESTED: aln �- - vieb COMMENTS: rtbf SAN jOgQu, 8 2021 HfgLTH � pA N7 -AL V ACCEPTED BY: , G EMPLOYEE #: DATE: 21-1812,t ASSIGNED TO: C EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 'J2 PIE: f W D f Fee Amount: Amount Pa � C/ Payment Date 2 2r Payment Type !moi Invoice # Check # 1 _ Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003