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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Small VVinery S �iI�q <br /> OWNER/OPERATOR <br /> John and Mary Lynne Franzia Family Trust/Latitude 37 Partners, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Zinc House Farm Winery <br /> SITE ADDRESS East State Highway 120 Escalon 95320 <br /> 20679 <br /> Street Number Direction Street Name Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7/✓` Street Number Lt treet Name <br /> CITY �, STATE �j ZIP c f f a <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (209 ) 595-8348 205-080-04 PA-�—� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CQ'pE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Paul Franzia CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME Latitude 37 Partners, LLC PHONE 595-8348 EXT. <br /> HOME or MAILING ADDRESS 20679 E. Hwy 120 FAX# <br /> CITY ESCalon STATE CA ZIP 95320 <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 or <br /> 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 rk to be performed will be done in accordance with all SAN JOAQUIN <br /> 7 <br /> COUNTY Ordinance Codes, Standards, STATE and Fla <br /> APPLICANT'S SIGNATURE: / DATE: Z'/Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Eco/V�D <br /> FE8 2 5 2020 <br /> GAN JOAQUIN COU <br /> HST►RONMENTAL TM <br /> ACCEPTED BY: EMPLOYEE M DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: o�� <br /> Fee Amount: p Amount Paid Payment Date <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />