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Y <br /> SERVICE RECUEST <br /> Type of Business or Property FACILFTY ID: SER �CE REQUEST m <br /> OWNER I OPERATOR BILLING Pr Rrr <br /> L <br /> FAaLi�r Naar= �� <br /> SITE ADDRESSS�L;1h <br /> L-1V".57 ° Numbr anc4ae A���n SCe�tNm� Type sut,y <br /> Mailin Address (If Different from Site Address) <br /> � �`L D� <br /> Crrr �n I�dMaYl C(-� 9 4°�s 7'� STATE Z1P <br /> Pl30NE <br /> 91 y Err. APN# LAND USE APPucA cN# <br /> PHONE#2 BOS 01 iCT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> RfOUESTOR BILLING PAlrT7V$� <br /> 'PC) `�.l.vt~. r� <br /> BUSINESS tiAn+E Shy <br /> PHONE#q;?j I Ext. <br /> MAlLjNG ADDRESS FAX# <br /> )q2,S- 20 <br /> em Cly t� STATE ;? <br /> BiLL1NG ACKNOIIVLEDGEMEfdT:1.the undersigned property or business owner,operator or authorized agent of same, acknowledge that alt site andlor project spedfic <br /> PuBUC HEALTH SERVICES ENvnCNMENTAL HMIH 1)i s*N hourly Charges associaLd with Ibis projector activity w 1 be haled m me or my business as identified en this brm. <br /> I also cemfy that I have prepared mis appixatzon and that the work to be performed will be done in accordance with ad SAN JOACIUiN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANTSIGNATURE:� DATE:,/ <br /> PROPERTY f BUSINESS OWNER C OPERATOR 1 hUWGER Cl OTHER AUTHCRiZED AGENT <br /> it APPY r wr is not tris Rx F 1,4 PAm,proof of avexvhudon to sign is roquind Title <br /> AUTHORl7ATI0N TO RELEASE INFORMATION:When appfcable,1,the owner ru operator of the property located at the above site address,hereby authwvB the release of <br /> any and ad results,geoleChniwl data andlor environmentakile assessment information to the Sul JOAQUIN COUNTY KuLk HEALTH SERVICES ENWONUENTAL HEALTH OMSION as soon <br /> as it is available and at the same lime it is provided to me or rrry representative. <br /> TYPE of SERVICE REQUEMD: <br /> t m ore. C )'50 <br /> COMMENTS: <br /> � t\.J}�t <br /> s IN <br /> P18L1G <br /> it <br /> INSPECTORS SIGNATURE: CONTRACroleSSIGNATURE: A' <br /> APPROVED BY: D EYT t,,— Gt IP �� DATE_' <br /> ASSIGNED TO: r �. � Ehipwya# � � � DATT <br /> 1, 1 <br /> j Data Service Completed (if already completed: 5edtvltsCoD �_i q PIE. <br /> Z <br /> Fee Amount Z Amount Paid Payment Payment Date f L <br /> Payment Type �; Invoice 9 Check# t Received By: <br /> I <br />