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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ! <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Coffee Shop 427)L sQCMZ l <br /> OWNER/OPERATOR - <br /> Parents by Choice, Tony Yadon CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Plaza Perks <br /> SITE ADDRESS E <br /> Main Street Stockton 95202 <br /> 306 Street Number I DireeUon I Street Name city it Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. BOX 690158 Street Number StreetName <br /> CITY Stockton <br /> STA FA <br /> Z'P 95202 <br /> PHONE 01 EXT. APN# _ LAND USE APPLICATION# I <br /> (209 ) 275-2487 I�� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 14 8 ) 796.2914 07 1 U <br /> CONTRACTOR/SERVICE REQUESTOR I <br /> REQUESTORj <br /> CNECK If BILLING ADDRESS❑ I`E <br /> BUSINESS NAME PHONE# E%T. <br /> t <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 /> i <br /> APPLICANT'S SIGNATURE: DATE: September 15, 2020 <br /> PROPERTY/BUSINESS OWNERC,{ t <br /> ^� OPERATOR/ A AGER OTHER AUTHORIZED ACENT❑ Executive Director <br /> lJAPPLICANT is not tire 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 envirotlmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i5 + <br /> provided to me or my representative. P c <br /> TYPE OF SERVICE REQUESTED: Consultation Inspection <br /> COMMENTS: C I <br /> SFp O <br /> FqH /OENPtJgIITyRAt61VA. Q <br /> Py , <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: t <br /> 6213 DATE: 9-15-20 <br /> ASSIGNED 70: Victor Acevedo EMPLOYEE#: 9832 DATE: 9-15-20 <br /> Date Service Completed (If already completed): SERVICECODE: 061 PIE: 1603 <br /> Fee Amount: 152 Amount Pai 5 a O Payment Date <br /> Payment Type Invoice If ICheck# Recely d By: <br /> EHD SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11117!2003 <br /> D v��46Ue4 :::4/70,bb <br />