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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property gFACILITY ID# SERVICE' (R'E'QUEST# <br /> Bakery I ��g ko01P`M-1 <br /> OWNER I OPERATOR <br /> Justin and/or Malory Zaklan CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Crave Cookies, LLC <br /> SITE ADDRESS 95366 <br /> 1043 S. AcaC'%AANumber Direction Street Name Ripon Ci Z Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 926 Cypress Point DG Street Number Street Name <br /> CITY STATE ZIP <br /> Ripon CA 95366 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 818)903-7160 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/'SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 /> 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: 6-23-22 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY 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. 1 I <br /> IJA EN <br /> TYPE OF SERVICE REQUESTED: C- N L-F�V�.f-h ` �, }`�� RECEI <br /> VIIA✓ VET <br /> COMMENTS: JUN 2 3 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH OEMRTMENI <br /> ACCEPTED BY: V r U r EMPLOYEE#: DATE: L -2- --2-� <br /> ASSIGNED TO: P <br /> EMPLOYEE#: DATE: I/O-L2 —�— <br /> Date Service Completed (if ready completed): SERVICE CODE: rT/_ PIE: (QO <br /> Fee Amount: Amount Paid Sa Payment Date <br /> Payment Type V b J Invoice# ChRIi#I Y s GZ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 C <br />