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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Establishment g S 1� <br /> OWNER/OPERATOR <br /> Justin Creel CHECK If BILLING ADDRESS <br /> FACILITY NAME Twisted Tulip Frozen Yogurt <br /> SITEADDRESS 1550 West Colony Rd 5'1 F tA` Ripon 95366 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5137 Almsbury Drive <br /> Street Number Street Name <br /> CITY Salida CA STATE ZIP 95368 <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (209 ) 341-9688 261-58-012 <br /> PHONE#2 Ezi' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Justin Creel CHECKIf BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Twisted Tulip Frozen Yogurt 209 341-9688 <br /> HOME Or MAILING ADDRESS FAx# <br /> 5137 Almsbury Drive ^ ( ) <br /> CITY Salida u// ���t(CC O A�' �J VOSTATE CA ZIP 95368 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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: DATE: 06/02/2020 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPz7cANT is not the MLL/nrG PAR 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. I <br /> TYPE OF SERVICE REQUESTED: e-„l/ rte' tt �t/(`�JJ J ry Y <br /> COMMENTS: t� ClV� / <br /> 2-7�i' OC <br /> AN V <br /> SANJp 4 <br /> HFA TM F41"COP/N <br /> ACCEPTED BY: Czr-v'I L& es C_p EMPLOYEE#: DATE: <br /> ASSIGNED TO: Gt- ki/K� EMPLOYEE#: DATE: 6 `Lf�--2<) <br /> Date Service Completed (if already completed): SERMCECODE: Sy3 PIE: ( /oCJl <br /> Fee Amount: Amount Paid SSD,vO Payment Date 4 <br /> LIL ZD <br /> Payment TypeVi� - Invoice# Check# 1 �(L�IS Received By: <br /> EHD 48-02-025 ^w e��So SR FORM(holden Rad) <br /> REVISED 11/17/2003 71 V'', �'t- <br />