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• ! � SERVICE REQUEST <br /> FACILITY ID SERVICE REQUEST . <br /> Type of Business or Property / � 714— �� <br /> — Z - (� /4 BILLING PARTY ) <br /> OWNER OPERA 10 <br /> FACILrY NAME <br /> SrE ADDRESS ctM <br /> am <br /> urn <br /> 'olr <br /> om <br /> Mailing Address (If Different from Site Add ssI <br /> C STATE <br /> Crrr �7 IP C �� <br /> ` LAND USE APPLICATION# <br /> A P N <br /> BOS DISTRICT LOCATION CODE <br /> PHONE n2 <br /> f <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQIIF.STOR <br /> PHONE 4 UT. <br /> � <br /> BUSINESS NAME _ -- --- --- '��—/5 ` <br /> /7 � FAx 9 <br /> `- <br /> MAILING ADORESS,,// <br /> G'' r STATE /y ZIP <br /> Orr r samC <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagent <br /> billed to me orma bus nless as dendfied on this forrrge Ulat ail site andlor mnlect specific <br /> ect dr acivity Y <br /> PU6LIC HEALTH SERVICES Er1VIRCNMENTAL HEALTH 0rASiCN hourlycharges assocated with this Prot <br /> licadon and Mat the work to be performed mM be done in accordance with all Sur JOAQUIN CwNTY Ordinance Codes.Standards,STATE and <br /> I Aso certify that I have prepared this BPP �. <br /> FEDERAL laws. <br /> GATE: <br /> APPLICANT SIGNATURE: '�� <br /> tYtANAGER O proof oOTHER AUTHCRIZED AGENT <br /> OPERATOR/ i i t 1 a <br /> PROPERTY I BUSINESS OWNER is not the @St,rp pry r judwaadon to sJgn is rt"irsd <br /> BAaPt4AGEcm <br /> h1ATION:When applicable,I.Me owner or operator of the property located at <br /> AUTHORIZATION TO RELEASE INFORthe above site address,hereby aulhonze the release df <br /> any and all results,geotechnical data and/or envlrcnmentaysite assessment into madon to rhe Sul JOAQUIN CCUNTY PUBLIC HEALTH$cRVICES EM/RCNMENTAL HEALTH ONISICN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> T'rPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CONTRACTOR'S SIGNATURE: <br /> INSPECTOR'S SIGNATURE: / <br /> :SIPLOYEE 9: DATE: <br /> ,APPROVED BY: /—�_ <br /> DATE: <br /> -siPLOYEc�: S <br /> ,ASSIGNED TO: % � �/�— ✓ /� •--� �I E: '�' <br /> SERVICE CCOE: l <br /> gate Service Completed (If already completed): <br /> =ee '•mount'. �` — Amount Paid <br /> �� — I Payment Date <br /> Payment Type I I Ill <br /> Received By: <br /> Invoice$ Check <br />