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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I/'( SERVICE REQUEST I f \ Type of Business or Property FACILITY ID# SERVICE REQUEST# Coffee Shop-No Seating ---' -- S Q OWNER/OPERATOR Dutch Bros Coffee CHECK if BILLING ADDRESS FACILITY NAME Dutch Bros Coffee-CA-0805 SITE ADDRESS 15135 Old Harlan Road Lathrop, CA 95330 Street Number I Direction I Street Name ch, Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 110 SW 4th St. Street Number Street Name CITY STATE ZIP Grants Pass OR 97526 PHONE#1 Exr' APN# LAND USE APPLICATION# ( ) 196-110-300-000 PHONE#2 Ear. BOS DISTRICT LOCATON CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Omar Garzon, Project Manager, omarg@gnicharch.com CHECK If BILLING ADDRESS® BUSINESS NAME Gnich Architecture Studio PHONE# 971-346-2525 Em. HOME or MAILING ADDRESS 1001 SE Sandy Blvd, Suite 100 FAx# CITY Portland STATE OR ZIP 97214 BILLING ACKNOWLEDGEMENT: L 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 05/13/2020 APPLICANT'S SIGNATURE: Date:2o2O.D6.ts n:0g:11-07'00' DATE: PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Time 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: c4zKJ C RAYMENF COMMENTS: rr MA �lCt�vx'c MAR l( 12020 SAN J040UM COUN rY ENVIRONMENTAL NEALTNDEMRTMENI ACCEPTED BY: fVLe—r, C-Ca EMPLOYEE#: DATE: ASSIGNED TO: t�'l EMPLOYEE#: DATE: Date Service Completed (if already Completed): SERVICE CODE: \f-- P I E: C Fee Amount: Ll5w— Amount Paid Payment Date 5!IS 2a Payment Type GInvoice## Check# Received By: EHD 48-02-025 1 44- /19 D 531) -3 -Z Z SR FORM(Golden Rad) REVISED 11/17/2003