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CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR JFE Franchising Inc f3Gdwfejli `.3- flicrijd - coin' CHECK if BILLING ADDRESS 5 <br />BUSINESS NAME Snowfox VVinCo 10 1 PHONE # <br />1 (713) 463-7777 <br />Ex r <br />HOME or MAILING ADDRESS <br />2021 Bingle Rd <br />I Fax # <br />1 ( <br />ciTy Houston STATE TX zip 77055 <br />561342 N A17-Y <br />/1/ZAir <br />APPLICANTS SIGNATURE: <br />PROPERTY / BttsiNEss OWNER?, ()PE OR/ MANAGER 0 OTHER AUTHORIZE() AGENT 0 <br />BATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property (sham- spact witk, Cepicrd <br />Sushi Kiosk inside of grocery store 39)t. ) <br />_ <br />FACILITY ID # <br />-cQco La <br />SERVICE REQUEST # <br />'G <br />OWNER / OPERATOR <br />JFE Franchising Inc CHECK if BILLING ADDRESS <br />FACILITY NAME Snowfox Wincol0 <br />SITE ADDRESS 5100 <br />Street N umber Direction <br />Montauban Stockton <br />Street Name City <br />95210 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2021 <br />Street Number <br />Bingle Rd <br />Street Name <br /> CITY STATE ZIP Houston 77055 &6 TX <br />PHONE #1 EXT. 1 APN # <br />I <br />LAND USE APPLICATION # <br />(713 ) 463-7777 1 I JUN <br />PHONE #2 Exi. <br />( 1 <br />BOS DISTRICT LoC411I4NSME i <br />."Al 7, <br />2022 <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 he billed io 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 />If APPLICANT ks not the <br />/NG PAR7T proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO REL-EASE 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 all results, geotechnical data andior 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. <br />TYPE OF SERVICE REQUESTED: Application for food permit <br />COMMENTS: We would like to open our overnight Sushi program inside of WinCo store. We are sharing <br />the seafood department kitchen with VVinCo once they leave at night. <br />ACCEPTED BY: - \ ...-- EMPLOYEE #: 61-2A 3 DATE: <br />ASSIGNED TO: EMPLOYEE #: , 54, .2 5 DATE: <br />Date Service Completed (if already completed): SERVICE COOE: 0 L, I PIE: wv2 <br />Fee Amount: Amount Paid /52.0D Payment Date <br />/3/ <br />2_ <br />Payment Type i ,..A___ Invoice # Check # /41...3 4306-G( Received By: <br />END 48-02-025 <br />REVISED 11/17/2003 <br />.722' SR SR FORM (Golden Rod)