Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> # <br /> �T <br /> Retail Sales and Service �� Z Oo 2yo t <br /> OWNER I OPERATOR Starbucks Coffee Company <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Starbucks Coffee <br /> SITE ADDRESS1810 Pacific Ave. Stockton 95204 <br /> Street Number Direction Street Name Ci 21 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2401 Utah Avenue South MS stop:S-SD10 <br /> SUM Number Street Name <br /> CITY Seattle STATE WA ZIP 98134 <br /> PHONE#1 Enr. APN# 127-042-17 LAND USE APPLICATION# <br /> ( 206)318-1575 <br /> PHONE#2 Ezr. BOS DISTRICT LOCATON CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Al Baez;Ari Feldman <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME [ARB Land Consulting Services];MCG Architecture PHONE# Ear. <br /> 510)517-1603;(949)553-1117 <br /> HOME or MAILING ADDRESS 5504 Felicia Ave.; 15635 Alton Pkwy,Suite 100 FAX# <br /> CITY Livermore;Irvine STATE CA ZIP 94550;92618 <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: Au DATE: 4/21/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Mime it is <br /> provided to me or my representative. / r 1 <br /> TYPE OF SERVICE REQUESTED: ` t, (C �y <br /> COMMENTS: .�( r <br /> ItG�ldltd � Stibw ' t*J SF4CN✓0 <br /> ye4 <br /> a ° arc-Alvyb M <br /> Bi �3MC <br /> EWtIbCon -4i&ntco "�rro�lT/f <br /> -� 5 0 21 -&9 as <br /> ACCEPT BY: V /3 LO EMPLOYEE#: DATE: <br /> ASSIGNED TO: P�-t 0 k"/ EMPLOYEE#: DATE: ' Z3 ---ZV <br /> Date Service Completed (if already completed): SERVICE CODE: SZ 3 PIE: <br /> f O <br /> Fee Amount: r1 Amount P LL(V n Payment Date <br /> !/ / <br /> Payment Type /.Sly Invoice# Check# ! 7G/� Receiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />