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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property AY FACILITY # Taylor Conterno SERVVIIgE REQUEST # CHECK If BILLING ADDRESS BUSINESS NAME ��AAl DATE: PHONE# DQO Restaurant- Starbucks DATE: `6^ 1 'z` — 310 781 -6250 Ext 5 HOME or MAILING ADDRESS OWNER i OPERATOR FAX Amount Pa i Starbucks Coffee Company Payment Date g CHECK If BILLING ADDRESS FACILITY NAME CITY Torrance STATE CA Starbucks SITE ADDRESS 613 I Carolyn Weston Blvd, Stockon 95206 Street Number olrectien Street Name city ZiP Cnde HOME or MAILING ADDRESS (If Different from Site Address) 2401 Utah Avenue South Street Number street Name CITY STATE ZIP Seattle WA 98134 PHONE #1 ExT. APN # LAND USE APPLICATION # (206) 318-1575 164-220-001 PHONE02 EXr• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR AY El Taylor Conterno ACCEPTED BY: A�\^� ,`^\ CHECK If BILLING ADDRESS BUSINESS NAME ��AAl DATE: PHONE# EXT. Glassman Planning Associates, Inc. DATE: `6^ 1 'z` — 310 781 -6250 Ext 5 HOME or MAILING ADDRESS P / E: ; Q FAX Amount Pa i 1111 Sartori Ave Payment Date g ( ) Invoice # CITY Torrance STATE CA ZIP 90501 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT Hourly charges associated with this project or activity will be billed to me or my business as identified on this form 1. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes•,.SYnndards, ; nd htDI Ai.laws. APPLICANT'S SIGNATURE: DATE; 08/10/2020 PROPERTY I BLSINEss OWNER❑ OI:RNIOlt / MANAGER ❑ OTHER AUTHORIZED AGENT® Project Manager -Agent (f APPLICANT is 1701 file I3111./N., i'. UUT proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPEOFSERVICE REQUESTED: E x AY COMMENTS:C E' 1 2/E D AUG 12 20220 SAN JOAQUIN COUNTY 1 ENVIRONMENT ACCEPTED BY: A�\^� ,`^\ EMPLOYEEM ��AAl DATE: ASSIGNED TO: ` ^ EMPLOYEE M DATE: `6^ 1 'z` — Date Service Completed (if already completed): SERMCECODE: S Z P / E: ; Q Fee Amount: ._ Amount Pa i �$' O� Payment Date g Payment Type Invoice # Check # 125218,S ecei d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 9