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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SER CE REQUEST#' <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> L <br /> FALL"[NAME <br /> srrlf?5t2��� <br /> StrM Num�r Oextion /vL�'"" Scat Nvm Type Suite 7 <br /> MailinAddress (If Different from Site Address) <br /> a BOK 5785- gm 3.5-ott�) <br /> CITY San Pa(nv7-i CA '"IH 51- 7--)S STATE ZP <br /> !!{NaN}#4 � APN# LalloUsCApPucArlort;# <br /> PHCNE#? <br /> ter. 80S DISTR= . LocATIoN Cane. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUE5TOR� BILLING PAxr�©b Del fv � <br /> BUSINESS NAME , )' G PNaNe q ZS 28 S 2 10 e�T <br /> MAILING ADoass DVS D f2-T— L% Pl F Zvi S4 <br /> FAX Z 20 <br /> crtr Con STATE Cylr ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,acknOwtecge that aIt site and/or project spec <br /> PUBLIC HEALTH SERYICES ENYIRCNMENTAL HEALTH Dtvts,GN hourly charges associated with Chis project or acevtty will be billed to me or my business as identified on this,arm- <br /> I also ceroty that I have prepared this appricathn and Mat the work to be performed:roil)be done in accordance with al SAN JCAOJIN COUNTY Ordnance Codes,Standards,STATE and <br /> FEL'Er7AL IaM. �J <br /> APPLICANT SIGNATURE: DATE- <br /> PRoPEaryIBuszwssGwNE7 C 1MANAGER 0 CTHEA ALMCRM AGENT rA <br /> If APR ravrr+s root the Btmy PAmr per)&of wfhorindon to sign is,*Wi vd Title' <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable,1,the owner or operator of the property bated at the above site address,hereby authorise the releaseof <br /> any and ail rwults,geotechnical data and/or environmennVsite assessment nlamiaticn to the SAN JCAWW COUNTY PUBUC HEALTH SERvrCES EsmcNU TAL HEALTH OMSION as soon <br /> as it is available and at the same tithe it is provided to me or my representative. <br /> Type OF SErMU REQUESTED: <br /> COMMENTS: <br /> i <br /> { <br /> I <br /> I <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROMBY: V 1� 1� E9PL--Y--1!: ` , � t� OATK" <br /> ASSIGNIcl1TO: t1 �'. l Ed4Pt0YEE# �J I DATE: <br /> Date Service Completed (If already comple ): SEw ECooE: 4. P, <br /> E• <br /> Fee Amount~ Z Amount Paid Payment Date <br /> Payment Type Invoice it Checic# Received By: <br />