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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Coffee Shop <br />FACILITY ID # SERVICE REQUEST # <br />OCDt9 11" 3 <br />OWNER / OPERATOR <br />CHECK if Starbucks Coffee BILLING ADDRESS <br />FACILITY NAME Starbucks Coffee <br />SITE ADDRESS <br />4103 Street Number <br />E <br />Direction <br />Morada Lane <br />Street Name <br />Stockton, CA <br />City <br />95212 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />, <br />Street Name <br />Crrv STATE ZIP <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 Taylor Conterno Email: Taylor©gpan.com CHECK if BILLING ADDRESS III <br />BUSINESS NAME GPA, Inc. <br />PHONE # <br />(310 ) 781-8250 ext. 5 <br />Err. <br />HOME or MAILING ADDRESS 1111 Sartori Ave, <br />FAX # <br />( ) <br />CITY Torrance STATE C A 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: /4t- C.e.i..2frtov DATE: 12/20/22 <br />PROPERTY / BUSINESS OWNER': OPE TOR / MANAGER 0 OTHER AUTHORIZED AGENT El Agent for Starbucks Coffee <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 a4 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: -"/ V D' <br />COMMENTS: DEC 2 , 1 2022 <br />Plans review for a remodel SAN joA <br />Electronic 1.i .EA/Viligt-i8V cou ALTH DE.NpagN rAiLA./ Ty <br />ARTA/4/r <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 12-21-22 <br />ASSIGNED TO: Dada Afonskaia EMPLOYEE #: 9825 DATE: 12-21-22 <br />Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br />Fee Amount: 468 Amount Paid 71 46s, p:::;, Payment Date <br />Payment Type VI...5 a_ Invoice # Check # 15q4 ,7 7 q pit Received By: <br />Payment 154497984 SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003