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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Coffee Shop 0-1S <br /> OWNER I OPERATOR <br /> Ripon Garden Apartments, LLC. CHECK If BILLING ADDRESS <br /> FACILITY NAME Austin's Coffee Crafters <br /> SITE ADDRESS 222 West River Road Ripon 95366 <br /> Street Number Direction Street Name cily Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 2998 <br /> Street Number Street Name <br /> CITY Turlock STATE Zip 95381 <br /> CA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 632-2647 308 261-030-34 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> JKB Living, Inc. CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Austin's Coffee Crafters 209 632-2647 308 <br /> HOME or MAILING ADDRESS FAx <br /> # 667-2742 <br /> P.O. Box 2998 <br /> CITY Turlock STATE CA ZIP 95381 <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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /of I v <br /> PROPERTY/BUSINESS OWNER OPE / R ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environ* ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a1>64 i ae it is <br /> provided to me or my representative. NOV <br /> //`�� c�/ <br /> TYPE OF SERVICE REQUESTED: ,YOV�> <br /> COMMENTS: $NVIR0UtNCO(/ <br /> � 4018 <br /> ��Ty p PARTMFNT Y <br /> ACCEPTED BY: ` '( CO 1 EMPLOYEE#: DATE: ', l X <br /> V <br /> ASSIGNED TO: r2/- EMPLOYEE#: DATE: Iq 1� /y <br /> Date Service Completed (if already completed): SERVICE CODE: S93 I P I E: <br /> Fee Amount: L (p 610 Amount Pai ��,0� Payment Date ' s- <br /> Payment Type OIL Invoice# Check# �! 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 T F7 !q-7 4 3 S <br />