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Jim Thorpe In� 462-9861 p.1 <br /> SAN JOAQM COTJNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUF,ST <br /> Type of Business or Pmnartv FACILITY ID.4 SERVICE REQUEST# <br /> OWNER]OPERATOR Y^S L_ <br /> ��,..•�v` r �I.�^ ��f f ��� C/SifBlLuhtGADORES@ <br /> Acarry NAME ,-^.0 --— / I I/' /i IL <br /> Alt -25 <br /> Street Nutnher p tree Name CC C s <br /> HOME or MAILING ADDRESS (if L1ifferentfrom Site Address) f 3 3 9' /7( ;,+r' 44 <br /> gleet Number -trset Name <br /> Girt STATE � ZIP f-7 .� <br /> MORE#1APN# LAND Use APPLICATION# <br /> cz �il ,3. <br /> PHONa#2 Exr. Bas DISTRICT LOCATION MODE <br /> CONTRACTOR 1 SERVICE REQOESTOR <br /> REQUESTOR �✓- . CHECK IfBILLI—NA DflRS-3-4 <br /> BUSINESS 1+IkME <br /> .//Z �'1 J� > PC NE tC✓�J / <br /> Donne or 3UlAt[.Itts ADRi?E35 CIL <br /> �Com / Z��} �� �y�!�•�j <br /> CITY t �% / STATE �il9. ZIP C� <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 ENvaONMENTAL HEALTH DEPARTm T hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that i have prepared this applica tha'the work to be performed will be done in accordance withal]SAN JOAQUIN <br /> CatJNTY Ordinance Codes,Standards,STA d RE 'J""'� 7-y <br /> APPLICANT'S SIGNATURE. rG-. , � D_�Tt<: <br /> PROrERTY/BGSINESSOWNER;© PE T ]VIA, GE • RAuTiioRiZED. Gx,,s-rA g�`'r"L'fG•��/1� <br /> fflPPLJC17dtrT' n the E1 G P,tR proof of aur rizadon to sign is required Title <br /> AUTRORIZA IQN TU REI.FASE IN RMATHON: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 environmentaUsite assessment <br /> indbanation to the SAN JOAQUIN COUNTY 1?NVIRON)ONTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE SOF SERVICE REQUESTED: ,�- �� g,� 4t e�Y�rz t�'u'�! C <br /> ENT <br /> COMMERTS. <br /> SEP 19 2013 <br /> SAN JOAQUIN COUNT <br /> ENVIROi'+AENTAL <br /> HEALTH DEPARTMEN <br /> AcCEPIED BY: EMPLOYEE#: DATE: <br /> ASSIGN ED TO: EMPLOYEE#: DATV <br /> Date Service Completed (if already completed): Smcr:CODE; PIE: <br /> Fee Amount: 375. Amount Paid 3N9 Payment Date <br /> Payment Type Invoice# Check# f 3�(o Received By: <br /> EHd48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />