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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Market Ga wgos <br /> OWNER/OPERATOR <br /> Ripon Terraza, LLC. CHECK If BILLING ADDRESS <br /> FAcriefraza Market <br /> SITE <br /> II ADDRESS ', West River Road Ripon 95366 <br /> 999 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 2998 Street Number Street Name <br /> CITY Turlock STATE CA zIP 95381 <br /> N <br /> PRONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 )632-2647 ext. 308 261-030-34 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209-632-2647 ext. 326 <br /> } CONTRACTOR / SERVICE REQUESTORu k-b/ r) .C�nI <br /> RE'QUESTOR <br /> JKB Living, Inc. CHECK If BILLING AODRESS11 <br /> BUSINESS NAME EXT. <br /> Terraza Market PHOJ 632 2647 308 <br /> HOME Or MAILING ADDRESS FAX# <br /> P.O. Box 2998 1209 667-2742 <br /> ,c" Turlock STATE CA zIP 95381 <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: 9/16/19 <br /> PROP ERTY/B USINESS OWN ER❑ OPERATOR ANAGER ❑ OTHERAurnORIZEDACENTd Community Dev. Coordinator <br /> IjAvruCANT is not the BILLING PARTY proof ojauthorization 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/AAAassessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at t/�g�St1191 a It is <br /> provided to me or my representative. ^F <br /> TYPE OF SERVICE REQUESTED: w (7 avN <br /> COMMENTS: <br /> h�T�°Ro UI,yC ZQ19 <br /> H pFp��A�Nry <br /> MFNT <br /> ACCEPTED BY: 'Y, O.n l,N EMPLOYEE#: DATE:OI�I'^ /ll <br /> ASSIGNED TO: S, � G ��kJ'^ EMPLOYEE#: DATE: W _ 1 <br /> Date Service Completed (if already completed): SERVICE CODE: (j2 PIE: <br /> Fee Amount: 40 rL � Amount Paitl 6 ,b� / Payment Date <br /> Payment Type Invoice# Check# 7U Rece(ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />