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ML <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#/ <br /> Coffee Cafe W g 3 <br /> OWNER/OPERATOR <br /> Starbucks Coffee Company CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Starbucks Coffee <br /> SITE ADDRESS 10602 Trinity Parkway Stockton 95219 <br /> Street Number I Dinal-nStreet Name CRY ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Strget Name <br /> CITY STATE LP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> I ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> TBD-required for permit issuance CHECK((BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> HOME or MAILING ADDRESS FAX# <br /> ( 1 <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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: Q- } ��� DATE:--31l-Izl <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Associate <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required 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 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. a4w OF, <br /> TYPE OF SERVICE REQUESTED: REC firic IV T <br /> COMMENTS: ,� h - - MAR <br /> SAN Jo 19 2011 <br /> AQLj C <br /> OUNr <br /> HEg0-HDE gR7M NTY <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 3-18-21 <br /> ASSIGNED TO: Stephanie Ranifiez EMPLOYEE#: 1084 DATE: 3_13_21 <br /> Date Service Completed (if already completed): SERVICECODE: 523 PIE: 1601 <br /> Fee Amount: 456 1 d-Amount Pai7�(p Payment Date 3 Z <br /> Payment Type ' Invoice# Check# )22,335/h Recei d By: <br /> EHD 48-02-025 �y� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 '�^ <br />