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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> Restaurant(Starbucks Coffee) 2--2-2-S2 �312 0() -94 S 3 S <br /> OWNER I OPERATOR <br /> Starbucks Coffee CHECK If BILLING ADDRESS <br /> FACILITY NAME Starbucks <br /> SITE ADDRESS W Benjamin Holt Dr. Stockton <br /> 3011 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2401 Utah Ave <br /> Street Number Street Name <br /> "' Seattle "E z'P 98134 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (206 ) 318-1575 <br /> PHONE#Z Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Taylor Conterno <br /> CHECK If BILLING ADDRESS <br /> PHONE# Ex . <br /> BUSINESS NAME <br /> GPA, Inc. 310 781-8250 5 <br /> HOME or MAILING ADDRESS FAX# <br /> 1111 Sartori Ave ( ) <br /> CITY Torrance CA 90501 ' 1000 a,n . c6yyt STATE CA zF 90501 <br /> BILLING ACKNOWLEDGEMEN : 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 <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: %4A4, Muse DATE: 11/23/21 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Agent for Starbucks <br /> If APDL/CANT is not the B(LLlNG 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. PJcc A' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 6(k6(A5--,'1"LG (PICL0-S N0P30 ? , <br /> 04 At �� <br /> iyEE 10 P30 <br /> rMENT <br /> ACCEPTED BY: CG. K t 5 �_; EMPLOYEE#: DATE: _: — <br /> ASSIGNED TO: D10 y Ll ��_ EMPLOYEE#: DATE: 1 _ <br /> Date Service Completed (if already completed): SERVICE CODE: t y_7 PIE: (O(j / <br /> Fee Amount: Amount Pa C15/�o Payment Date <br /> e <br /> Payment Type /,5w Invoice Check 135 77 Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />