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SAN JOAQUIN COUNTY ENVIRONMI NTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADORES <br /> Mr Greg RaussPr/E1,-anr)r Ra <br /> FACILITY NAME <br /> Rausser Pro e <br /> SITE ADDRESS 11964 E Liberty Road Galt 95632 <br /> SVeat Number DirectiontreetN Zi ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) East Liberty <br /> 2000 Street Number Sheat Nama <br /> CITY STATE ZIP <br /> Galt California 95632 <br /> PHONE#t APN# LAND USE APPLICATION# <br /> I I Ozl7 -- (,30- fC unassigned <br /> PHONE#2 E+. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# Ev' <br /> Nail 0- Anderson and Asqriciatpq Inn (909)'167-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial W (209)369-4228 <br /> CITY Lodi <br /> STATE CA ZIP <br /> 95240 —J <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 be billed to me or my business as identified on this form. <br /> 1 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,�STPTE and FEDERAL <br /> laws. <br /> APPLICANT'S SIGNATURE:'[/ om^ + AV DATE: /-.70-bG <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <br /> IfAPPLICANT is not the B/LJNG PARrr proof of authorization to sign is required nue <br /> AUTHORIZATION TO RELEASE 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 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. �- <br /> TYPE OF SERVICE REQUESTED: �U R-FT4LE 9—,-4 ",R-r/4 C& <br /> COMMENTS: 3 RECEIVED <br /> ����r , �✓�,..._,u• ` �� JAN 2 5 2006 <br /> �d�i7ic�ct�?%- '% •�'' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> APPROVED BY: b E EV E-E 10 rt EMPLOYEE#: 03-1 DATE: / D& <br /> ASSIGNED TO: I..t c-4 I ri A EMPLOYEE#: s-.3V 10 DATE: / ZS/o& <br /> Date Service Completed (if already Completed): SERVICE CODE: 3/S' PIE: 2&.03 <br /> Fee Amount: / �(o,E� Amount Paid yLQ p Payment DateL6 6 <br /> Payment Type ✓ Invoice If Check# a�� Received By: <br /> EHD 46-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />