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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILIAi# SERVICE REQUEST# <br /> Coffee 5��� 43Cj <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRES <br /> Zoyla Cifuentes S <br /> FACILITY NAME <br /> Corral Coffee at Bella Terra Plaza <br /> SITE ADDRESS �I <br /> 1110 -street Number Direcaon Kettleman DriVglreet Name Kiosk 1 Lodi cit 9 Vde <br /> HOME or MAILING ADDRESS (N Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E�' APN# LAND USE APPLICATION# <br /> PHONE#2 ET. BOS DISTRICT Locanow CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Zo* Cif tenets CHECK if BIWNG AOO <br /> BUSINESS NAME PHONE# <br /> Corral Coffee LLC 925 478-9678 <br /> HOME or MAILING ADDRESS FAX# <br /> 710 Chagall Lane ( ) <br /> CITY Stockton STATE CIL LP 95209 <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 /> -A 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 Cones,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE; g� DATE: 02/27/2023 <br /> PROPERTY/BUSINESS OWNER14 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPL1CIrVTisnotlheB1LLIlyCPARTt'proofofauthorizationtosignisrequired 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 enduonmpewntaa site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an RlfUlt le it is <br /> provided tome or my representative. 115F.- <br /> TYPE OF SERVICE REQUESTED: C D VA S'U.lu'h F <br /> COMMaNTS: <br /> 'AlV JOA <br /> f;'WhoUIN COUNTY <br /> NMLTNDENrAL <br /> Epmr NT <br /> ACCEPTED BY: Y1,a cb- EMPLOYEE#: 9g DATE: <br /> ASSIGNED TO: ��'L1,, .. u' wtZ EMPLOYEE#: M WE: r7 ;�� 2J <br /> Date Service Completed (if already completed): SERVICE CODE: DW P/E: (XD <br /> Fee Amount: 1 Amount P�l� �5�,v� Payment Date Z3 <br /> Payment Type J---)—Ib Invoice 4eck.# /S OS ceiypy <br /> EHD SED 1125 SR FORM(Golden Rad) <br /> REVISED 71/77/2003 I <br />