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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ice Cream Shop Fa m 01 g 334 S R 0 0 21 g 4 7 <br /> OWNER/OPERATOR Tasty Treat Holdings LLC <br /> CHECK If BILLING ADDRESS <br /> (Attn:Dana Rakvica) <br /> FACILITY NAME Baskin-Robbins <br /> SITE ADDRESS 10742 Trinity Pkwy Suite B Stockton 95219 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1000 3rd street Unit 906 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> San Francisco CA 94158 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 720 ) 480-4523 - 44 <br /> PHONE#2 EXT. EMAIL I BOS DISTRICT LOCATION CODE <br /> ( ) dana@dapushgroup.com <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tasty Treat Holdings LLC CHECK if BILLING ADDRESS <br /> (Attn:Dana Rakvica) <br /> BUSINESS NAME dba Baskin-Robbins PHONE# EXT. <br /> ( 720 ) 480-4523 <br /> HOME or MAILING ADDRESS FAX# <br /> 1000 3rd Street Unit 906 ( ) <br /> CITY San Francisco STATE CA ZIP 94158 EMAIL dana@dapushgroup.com <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: 3/4/2024 <br /> PROPERTY I 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 atPA to <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment irpd <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided <br /> representative. • C <br /> TYPE OF SERVICE REQUESTED: S ?O2y <br /> COMMENTS: lgp&WlfRO..U/N COU <br /> We are taking over ownership of the Baskin-Robbins location on March 20,2024 at 10742 Trinity Pkwy,Suite B,Stockton,CA 9521 flie-Etqr�'VY 1,4L <br /> ,N Y <br /> Baskin-Robbins with the same staff,same menu,and same management.No equipment or property changes are being made.Only ownership oAg,�EN <br /> The purpose of this service request is to initiate the process to gain a health permit under our ownership.Service request payment confirmation is below. <br /> Service Request Payment confirmation#177572783 <br /> ACCEPTED BY: L <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: '7 ._- ^2tt <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: /„ Amount Pa' /6z co I <br /> Payment Date 32-1 2 <br /> Payment Type �, �,� Invoice# Check# 17 75 7753 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />