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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1632 - Restaurant/Bar 1-20 seats <br />FACILITY ID # <br />rAo � Cl � <br />SERVICE REQU S # <br />� <br />OWNER / OPERATOR Carmen J. Valenzuela <br />FAX# <br />( 1 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Inspired by Taste, Inc. DBA A Matter of Taste <br />SITE ADDRESS 115 <br />Street Number <br />I Direction <br />1 E. Main Street <br />Street Name <br />Ripon <br />City <br />95366 <br />Zip Code <br />ROME or (NAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #i (209) 924-5006 ExT. <br />( ) <br />APN # <br />S <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( I <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR` <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS I <br />FAX# <br />( 1 <br />CITY STATE ZIP <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: Carmen J. Valenzuela DATE: 02.24.2020 <br />PROPERTY / BUSINESS OWNERLli7 OPERATOR / MANAGER ❑ O'T'HER AU'T'HORIZED AGENT ❑ <br />If APPL7CA:V7' 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 at the <br />above site address, hereby authorize the release of any and I results, geotechnical data and/or environmental/site assessment <br />information to the SAN JO.AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availableG�t�ie same time it is <br />provided to me or my representative. Ioxt tC1�� �' <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: L©� � / �-� <br />[7 l.� /�wI <br />L ^ <br />/�/ ✓ <br />�, bZ 5 Z <br />S I JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: �) /� <br />P 1 E: <br />Fee Amount <br />2/ <br />Amount Paid <br />S <br />Payment Date <br />Payment Type V <br />Invoice # <br />ck # s -(p <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />er-0 5 Z-Oli� <br />