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CITY OF RIPON Fax:2095992685 Jul 18 7:53 P. 02 <br /> SAN JOAQUIN COUNTY E"MONMFMAL HE"=DEPARTIYIENT <br /> SERVICE REQUEST <br /> Type of BUsineea or Property FACM ID! SfERVIC6 REQUESY i <br /> OWNERI OPERATOR CrrEerrx <br /> FACRRY tlurs <br /> InAtwaEss nacre a+P� �Pm� ytS361�' <br /> MOTE oft <br /> Lir f apgi ADOpM pr of wom flom Site Address) <br /> A<g.. -STATE ZIP .. <br /> .. _SNE +, . Err. APR / LAND USE APPUGATION it . <br /> PNotE12 EA: , <br /> .. Still DISTNeT L.OeAT10N CODs <br /> ( <br /> CONTRACTOR/SERVICE REQUESTOR <br /> PMOSrOk cNseNe ,. '•. '. . <br /> PHONE# sir. <br /> Now OR MAa,IN3 AO FA%R <br /> STATE - zip <br /> CRT <br /> L the undersigned property or busluess owner, operator or authorized agent Of samc, <br /> acknowledge that-all site and/or project specific EWWNMENTAL HEALTH DEPARTMBNT hourly chargeeasaoclated with this pmJect . <br /> or.activity will be billed to me or my baldness as ideutiSed on this tb[m.' <br /> I aLw oerdfy,that I have prepared this application and that the work to bo ViNfOrmed will be done in accordanee with ell SAN JOAWN <br /> COUNTY OrrGmmce Coder,&w dar T: ATE and FPDERAL laws.._ <br /> APPMCANT'SSIGNATUTtE DATE: . <br /> PaoPRaTv/HUSDaW0Wx=0 0MATYm/MANAGzR Q OrKZRAUTHOiarz®ACaNr <br /> If APP=4NT 0 not she 02.&=Proof of 0 r&o rkaddN eo state it r.9+rlred zt r <br /> When applicable,I,the owner or operator of the property located at the <br /> above lite address: hereby authorize the release 0f'any and al mgW% Woolm oal data and/or environmentaVsu assesemept <br /> information to the SAN JOAgJ]N COUMY ENVIR0NMMrrAL IIBALTH DUARTN� a8 soon as it is available and at the game time itis' <br /> provided:to meor my representative. <br /> PAYMENT <br /> '7YPEOF.SuwERMUE W! Fy'nr / bRA S <br /> res_ JUL 18 2007 <br /> w <br /> SAN JOAQUIN COUNTY <br /> It . ENVIRONMENTAL <br /> (J� HEALTH PLODEPAR <br /> R„ I:aITeIe�: DATE:AcWTED <br /> .. <br /> AsEW=T0: EMPLOYEE V DATE: <br /> Data Seri completed (MatrwdyeanPlet a): SEavICECooe PIE: <br /> Fee Amou;W U Amount Paid .� c7 Payment Dat® Z 0 <br /> Parnant Type IRvo14!a« .l bt 15'I'l Ck';k: �7 b MOW. <br /> VO 46-02-M .8R FOIEY(fi0lpal Rdd) . <br /> REVZFD 1 i1178008 <br />