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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Starbucks Coffee <br />FACILITY ID # <br />(c -?-' g <br />SERVICE REQUEST # <br />6 (ZODZ54g <br />OWNER! OPERATOR <br />Starbucks Coffee CHECK if BILLING ADDRESS <br />FACILITY NAME Starbucks Coffee <br />SITE ADDRESS <br />1451 Hulsey <br />Street Number Direction <br />Way <br />Street Name <br />Manteca <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 2401 <br />Street Number <br />Utah Ave <br />Street Name <br />CITY Seattle STATE WA ZIP 98134 <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Taylor Conterno "tykr-- 9.1ba..44_, o. "CY72ITECK if BILLING ADDRESS <br />BUSINESS NAME GPA, Inc. PHONE # Er-. <br />( 310 )781-8250 5 <br />HOME or MAILING ADDRESS 1111 Sartori Ave FAx # <br />( ) <br />Crry Torrance STATE CA ZIP 90501 <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: / eie3it&ZW <br />PROPERTY/BUSINESS OWNER El PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El Agent for Starbucks <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: D.,e,,,Avve,U , ,-,.412. 11-1 3 cy)be c-1,1-•)9 FEB 15 202 <br />COMMENTS: <br />CA eCit-A k2- (7 GI- L-t _s. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />C&LA/litit e6cc, EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />A-C3L1/101./ <br />EMPLOYEE #: DATE: 2-15T-- 2-3 <br />Date Service Completed (if already completed): SERVICE CODE: ;-2, PIE: /60( <br />Amount Paid 4i V6, x Payment Date Fee Amount: 41_0&-• <br />Payment Type VI (.. fi Invoice # S.litra # i Sla to b g cl. 6-7- Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br /> <br />DATE: 2/1/23 <br />