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• SERVICE REQUEST • <br /> Type of Business or Property F 10✓< SERVICE REQUEST <br /> ACILffY <br /> 381q' 2� <br /> OWNER OPERATOR ^ T BILLING PARTY <br /> `J rrh <br /> FACILrrY NAME <br /> SITE ADDRESS <br /> Mailing Address (If Different from Site Address) <br /> Ciff STATE ZIP <br /> PHONE91 W APNA LAND USEAPPLICATioN9 <br /> PHONE1I2 - ErT• BOS DISTRICT LOCArioN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQuESTOR (/, BUJNG PARTY' <br /> BUSINESS NAME PNotrEII N1r. <br /> MAILING ADORESa FAX S <br /> On SIATE ZIP p;�e � <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authodud agent of same,admaledga that all site ardor project specik <br /> PUBLIc HEALTH SERvICES E MdiCt6AEHTAL HEALTH D houdy clo ges associated wdh Nis project or ardNAy wig be billed N me or my business as identified on this turn. <br /> 1 also cer*that I nave pmpared this application and Nat the work to be performed will be done in acowdanca WM all SATS JOA*m COu;NY Ordwn Codas,Slaodards,STATE and <br /> FEDERAL Iawz. / �/ �t <br /> APPUCNIT Sw;NAT . CODRE:- L+ DATE: f/ / '��0�f�- <br /> PROPERTY/BusmESS OWNER ❑ OPERkICR/MANAGER 14 CrHERAUnrarrMACENT ❑.�'A/ 61;e <br /> YAPnxarrarctds BUACP.vm.pmfdwdmorhatlan toaipo6reprid Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When apps able,L Ma amwof operator of UN property)orated at Ne above site address,hereby aumortze am micase of <br /> any and all results.geotechniml data andlor eavirmrrnWfsira assavment i formatM to Mq SAN Jaouer COUNTY Pu&Ic HEALTH SERom ENvRoNu NTAL HEALED DMSION as soon <br /> as A Is available and at Ne same time A is provided to me or my mpresmmMva <br /> TYPE OF 5ERvicE REQUESTED: G <br /> COMMENTS: <br /> R�cE SEC <br /> sq"VOV a 62001 <br /> "IJO <br /> OIOVIRNl1NSR� sqH Vu <br /> INSPECTOR'S SIGNATURE:���l// CONmACTOR"S SIGNATURE: <br /> APPROVED BY: /��i/ EIIPLAY�JM; GJ/s DATE: <br /> ASSIGNED To: •' 1 /m n 1 EwwYEE#. 3S DATE: <br /> {rf <br /> Data Service CompletedaI completed)): lJ SERvkECDDe 1�� PfE23 <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type G Invoice Check C Received By: �,r> <br />