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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # El SERVICE REQUEST # food CHECK if BILLING ADDRESS BUSINESS NAME �-' Wine and pairing ExT. The Vine House OWNER / OPERATOR 632-2647 308 Ripon Garden Apartments, LLC. CHECK if BILLING ADDRESS FACILITY NAME 667-2742 The Vine House -T SITE ADDRESS 222 West River Road STATE CA Ripon 95366 Street Number Direction Street Name city Zit) Code HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 2998 Street Number Street Name CITYTurlock STATE ZIP 95381 CA PHONE #1 ExT• APN # LAND USE APPLICATION # ( 209) 632-2647 308 261-030-34 #2 ExT• --7PHONE BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I Irk El JKB Living, Inc. -APP hl��RONME DUty1y TN CEP4R E T CHECK if BILLING ADDRESS BUSINESS NAME EMPLOYEE #: n v PHONE# ExT. The Vine House EMPLOYEE #: 209 632-2647 308 HOME or MAILING ADDRESS SERVICE CODE: '1 - , # 667-2742 P.O. Box 2998 (Ax 209) Payment Type �.� CITY Turlock STATE CA ZIP 95381 BILLING ACKNOWLEDGEMENT: I, 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. 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 7 DATE: 3/25/19 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmentaft sssesssment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atAb Nj4rbs provided to me or my representative. C �� TYPE OF SERVICE REQUESTED: I I Irk 1< ( J% ( nn COMMENTS: C+ j ( Ii 12 91 19 -APP hl��RONME DUty1y TN CEP4R E T ACCEPTED BY:14 C-0 EMPLOYEE #: n v DATE: C C / ASSIGNED TO:15. EMPLOYEE #: DATE: C� Date Service Completed (if already completed): SERVICE CODE: '1 - , P I E: Fee Amount: C GI� Amount Paid Payment Date Payment Type �.� Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)