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r CITY OF RIPON Fax:2095992685 Jul 18 2007 7:53 P. 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I)EYARTMENT <br /> SERVICE REQUEST <br /> TV"of i3ueinm or Propedy FACN.ITY ID# SERVICE REQUEST# <br /> 1:3c�Ncsasroa � . <br /> OWNERI OPERATOR CNECxN <br /> FADRm NAME <br /> d �InJ .. . <br /> SITE ADDRESS <br /> ' I <br /> NOME or MAIUNG ADDRESS (N oftrdnt from Site Addross) <br /> .. // .STATE LP <br /> 4f..3Ao <br /> EXr �# LAND UsE APPIAOATION# <br /> PHONE <br /> o / <br /> En BOS DISIAICT ('� LOCAnnN CODE <br /> PHONE 12 - /l <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If�lyyy�gDBEEr°. <br /> PHDNE# ' <br /> BusiNFas NAME: ' <br /> FAX# <br /> HOMEOr NWLINc ADD SS <br /> STATE LP <br /> CITY <br /> I the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific EWIRONmENTAL 1jEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed tome or my business as identified on this form. <br /> I also=tify,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,13ATE and FEDERAL laws.. <br /> APPLICANT'S SIGNATEM. DATE: <br /> PROPERTY/BUstNessowrtasI13 0MATOR7D'fANAGER 13 Drama AuTHowzED AGYNT9 <br /> IfAPPLIC4NTis notdw 89LMPABZE proof ofourkorizNiin to sign is required Tlt e <br /> O Ag - 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 and/or enviremnema/site Assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HSALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> PAYMENT <br /> TYPE OF.SERVICE REQUESTED: RJFVIIrA,,1 DRAT,)/ (r <br /> COMMENTS! . <br /> JUL 18 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAR <br /> EMPLOYEE#: DATE: . <br /> ACCEPTED BY: . <br /> Assi NED TO: EMPLOYEE#: O b DATE' <br /> Date Service Completed (N alreadyCOMPleted): 5FRVICECODE: <br /> Fee Amount: U Amount Paid -IF .(CIO • U (j Payment Daft —7 0 <br /> Payment Type Imrolts# Check# a7 b Received 13Y. <br /> . .SR FORM(Goken Rod) . <br /> EHD 4802-025 <br /> REVISED 1111712003 <br />