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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property — FACILITY ID# SERVICE REQUEST# <br /> 1632 - Restaurant/Bar 1-20 seats F)4 0 00 c '.00 GA <br /> OWNER/OPERATOR Carmen J.Valenzuela CHECK If BILLING ADDRESS <br /> FACILITY NAME Inspired by Taste, Inc. DBA A Matter of Taste <br /> SITE ADDRESS 111 E. Main Street Ripon 95366 <br /> Street Nember Direction Street Name city Zip Cotle <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> I 1 (209) 924-5006 <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> I ) <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 ENvIRONPofENTAL 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: 04.20.2021 <br /> PROPERTY/BusiNESs OWNERL1a OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> VIAPPLICANT is not the B/LLWG 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 rX results, geotechnical data and/or envirownenAia assessment <br /> information to the SAN JOAQUIN COUNTY ENv[RoNMENTAL HEALTH DEPARTmENr as soon as it is available and VQ- it is <br /> provided to me or my representative. C T <br /> TYPE OF SERVICE REQUESTED: <br /> AP <br /> COMMENTS: SAN✓p <br /> OZI <br /> etvvjHeq Ty��pgR rMFNT Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: Lr 2,0 22 / <br /> Date Service Completed'(if already mpleted): SERVICE CODE: 6 1 PIE: 16 D 2 <br /> Fee Amount: CJ�,' Amount Paid 6:2.()0 1 <br /> Payment Date 71J <br /> Payment Type `�� Invoice# Check# / -2ZI3�, 72 2- 1 Received By: <br /> EHD SED 11/1 ///��� Z�I n SR FORM(Golden Rod) <br /> REVISED 11/17!2003 (/�6 ��� D v� <br />