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K] New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel <br />License Plate Number VIN <br />^S^Billing Party □ Facility Owner ^Architect□ Facility Contact □ Property Owner □ Contractor <br />^Architect□ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />If contractor, indicate type and license number <br />Address City State ZIP5858 Wilshire Blvd., # 200 Los Angeles CA 90i <br />Phone <br />3^Property Owner□ Billing Party □ Facility Owner □ Facility Contact □ Contractor <br />First Name Last name MickelDrew <br />City StateConcord CA <br />Phone <br />Ji^Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party <br />If contractor, indicate type and license number <br />ZIP <br />98134 <br />Phone <br />08/06/2025DATE: <br />□ OPERATOR / MANAGER XI OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER <br />Linked I AIDAccepted By <br />PE FeeLkoi <br />□ Cash □ Check II <br />Rev 07/10/2024 <br />Address <br />2401 Utah Avenue South <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />® Other <br />Tenant Improvement <br />/T <br />D <br />First Name <br />Josh <br />Email <br />drewm@reynoldsandbrown.com <br />Email <br />entitlements@valerioinc.com <br />Last name <br />Bennett <br />City <br />Tracy <br />Phone <br />(415) 918-1743 <br />Phone <br />323.954.8996 <br />Email <br />JOBENNETT@STAffiBUCKS.COM <br />State <br />CA <br />ZIP <br />95337 <br />^Confirmation U <br />City <br />Seattle <br />Type of Service <br />Requested <br />Comments INTERIOR tenant improvement in a newly constructed shell with drive thru window by landlord, scope of work is comprised OF NEW NON- <br />Address <br />1200 Concord Avenue, Suite 200 (R & B DELTA II, L.L.C.) <br />Phone <br />925-674-8400 <br />Facility Name <br />Starbucks <br />Site Address <br />1102 International Parkway, Tracy, CA <br />APN <br />209-480-05 <br />Planner <br />Title <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al! site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />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 COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. . <br />APPLICANT'S SIGNATURE: 7'£rr <br />State <br />WA <br />I JS^Billing Party <br />Agent <br />First Name <br />Steven <br />Record Number <br />AP2.5^2511______ <br />Payment <br />Received By <br />v'y'vttfC of <br />Date^-- _ <br />Assigned To i <br />L iV\ I] oczyg r <br />Last name <br />Youn <br />If contractor, indicate type arfffliJO^^mber ’ <br />__________