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SAN JOAQUIN COUNTY ENYHtONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS 5858 Wilshire Blvd #200 SSE CITY Los Angeles STATE CA ZIP 90036 SqN SFP 0y r a ��t jERVVICE/�REEQUEjSST## v ` 04 Coffee Cafe I I"i5 OWNER / OPERATOR ACCEPTED BY: t..:t.1/✓� CHECK If BILLING ADDRESS Starbucks Coffee Company DATE: FACILITY NAME EMPLOYEE M SITE ADDRESS I Mountain House & Byron Mountain House 95391 Street Number Dlrect1cm Street Name Payment Date 9 9 2 CII ZIP Code HOME or MAILING ADDRESS (If Different fromite SAddress) Received By: �y, Z 1 `(t Street Nu Street Name CITY Ot 't STATE', / ZIP PHONE#t Ex . APN # LAND USE APPLICATION # ( ) 209-040-17 PHONE #2 EMT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Noelia Santiaco BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS 5858 Wilshire Blvd #200 FAX# ( ) CITY Los Angeles STATE CA ZIP 90036 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. APPLICANT'S SIGNATURE: Alodu DATE: 09/08/2021 PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTRER AUTHORIZED AGENT ® Associate If APPL/CANT is not the BILLING PAR TP proof ofaathorization 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 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: Plan Check ^1 COMMENTS: Commercial tenant improvement, interior only. Scope includes new non-structural partitions, CF equipment, fixtures, finishes, lighting, furniture. ltcf,,*s►�rz �,aNs N ��ys ss SqN SFP 0y r a ��t "t,4" 0�QuMF�o ACCEPTED BY: t..:t.1/✓� EMPLOYEE #: DATE: ASSIGNED TO: �jn � EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: Sz3 PIE: IV Fee Amoun . S Q� Amount Paid S(� Payment Date 9 9 2 Payment Type lL� Invoice # Check # 3 t�-33 �� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 r 2i