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Jim Thorpe Inc62-9861 p.1 <br /> 0 . * <br /> SAN JOAQM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business of Pronartv FACILITY ID 4 SERVICE REQUEST# <br /> OWNEFOOPERATort <br /> FAcftm WE 4 <br /> SiTEM ZC <br /> 'Ie"41 <br /> M6-36—tNZber <br /> How or MAuNa ADDRESS (ifUlfferentfrom Site Address) 12- 33 9� <br /> Street Number root Name <br /> GritSTATE ZIP <br /> APN# LAiqo USE AppucAnoI4 0 <br /> PHONE 192g- DISTRICT LOCKRM CODE <br /> (26) 26-1 11 <br /> CONTRACTOR SERVICE REQUESTOR <br /> ReQUESTOFE CAECK If Blwaftmdl <br /> ZZ11,617 <br /> B=Nus NAmE ;1PH NEft�n 2f,) <br /> �kwsoM <br /> rA&tl*GADDREss PAX# <br /> STI.TE zip <br /> Crry zoo/ <br /> BILLING ACKNOW��LMENT: 1, the undersigned property or business owner,operator or autborized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL H&,kL'rH DEPARTMENT 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 appli the work to be performed will be done in accordance with all SAN JO.AQUIN <br /> COUNTY Ordirmce Codes,Standards,STA=rL>vr&' 147"e <br /> 61Z 7-y <br /> APPLICANT'S SIGNATURE. Fyr-l'd <br /> E Z-V12DAIE: <br /> A <br /> S ow 13 M P4 MA VtTmRAuTH03uzED AGaNTO CaL7,31 755Z:�feZ�21K <br /> PROP13UTY I BUSI;NLSS OWNIR <br /> PLitr'�'r a BILANG PART111woof-of aufh0r1Zad0R to Sign is required Title <br /> AUT11QB1ZMQN TO I LEAfip-IN <br /> %N When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geoftelmical data and/or environmental/site assessmert <br /> information to the SAN JoAQuilsi CoLwry ENVIRON'XIENTAL HEAL*m DPPARTmENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SER=E MuEsTED: <br /> COMMEXT7. <br /> AccEPTEo BY: EMPLOYEE DATE. <br /> ASSIGN EDTO: EMPLOYEF-#: DATE: <br /> Date Service,Completed (if already completed): St= Ice CODE; TPIE: <br /> Fee Amount* Amount Paid Payment Date <br /> Payment Type Invoice# Chick# Received By: <br /> EHD48,02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />