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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY 10# SERVICE REQUEST# <br /> Type of Business or Property gc?)< R 0 443 <br /> Coffee Shop O I <br /> CHECK if BILLING SO <br /> OWNER I OPERATOR <br /> Deets Coffee & Tea <br /> FACILITY NAME Peets Coffee &Tea <br /> Pacific Avenue, Suite C-125 Stockton 95207 <br /> SITE ADDRESS rJ76r� Ci Zi Code <br /> Street Name <br /> Street Number Direction Park Avenue <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1400 street Name <br /> Street Number ZIP <br /> STATE 94608 <br /> CITY Emeryville CA <br /> Ext. APN# LAND USE APPLICATION#- <br /> PHONE#1 <br /> (510 ) 594-3241 LOCATION CODE <br /> PHONE#7 <br /> Exr BIDS DISTRICT <br /> ( ) CONTRACTOR 1 SERVICE REQUESTOR <br /> REGLUESTOR Byung Yoon CHECK If BILLING ADDRESSO <br /> PHONE# Ems' <br /> BUSINESS NAME ACS 714 436-9000 <br /> HOME or MAILING ADDRESS FAX# <br /> 1122 Bristol Street ( 714 ) 436-9055 <br /> CITY Costa Mesa STATE CA ZIP 2626 <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: DATE: 3/17/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERA R/MANA ER AU71"HORIZED AGENT® Project Architect <br /> If'APPLIC'ANT 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. <br /> TYPE OF SERVICE REQUESTED: Plan review approval on addition of new refrigeration and warming OR enaMefA.�. <br /> COMMENTS: F:-boO(a Vl ' 'I...J '/ <br /> MAR 18 26i5 <br /> E1VVtRQVM&jTAL <br /> piE�ulr/SERWC S rN <br /> ACCEPTED BY: EMPLOYEE#: DATE: S(4 <br /> ASSIGNED TO: &AMZA <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2� P!E: 1r�6 <br /> Fee Amount: Amount Pa A 25cv�v� Payment Date <br /> Payment TypeInvoice# Check# I / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> RF1/ICFrI 1 1 1171�f1(1'� <br /> s <br />