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. I • SERVICE REQUEST 0 <br /> Type of Business or Property FACILITY ID err SERVICE REQUEST <br /> OWNER OPERATOR BILLING PARTY B' <br /> FAcIurY NAME <br /> STTEADDRESS <br /> iiy80 53.aH ror S. V 11 C7sarAmt ry,. s�.r <br /> Mailing Address (If Different from Site Address) <br /> N; CITU' STATE ZIP <br /> PHOHE41 W APN9 LAND USE APPLICATpN9 <br /> ( <br /> PHONE 92 EDIT. 806 OtsTRlcr LOCATION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> / REQUMOR BILLING PARTY❑ <br /> MAP- ulcilr; _ftE <br /> BUSINESS NAIE ? PHONE# �• <br /> fo L. `i 593 -d lvs <br /> MAILING ADDRESS I FAX J ys <br /> ti 3S �. ' ctvtvArl ,a 94(J Y <br /> CITY IL L STATE e,A ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, admuwledge Gut all site andlor project specific <br /> PUBLIC HEALTH SERVICES&N1RUQIENTAL HEALTH Oros"hourly drarges associated with this prof dor aatvity will be billed to me or my business as identified on Gds tam. <br /> I also cadfy that I have prepared this application and Mat the work to be performed will be done in acc=dana with all SAN JOAam CwYYY Ord6mnce Codes.Sf nd&ds,STATE and <br /> FEDERAL laws. <br /> ,--XPLICAHTSrAATUIV: DATE: G rIIC 1 <br /> PROPERTY IBusIHESSOWNER ❑ IMANACER ❑ 0RNERAUn+oN= <br /> YAwUcW4lictdw BarnaPARM proldwdWt0doe to ZIP bnwid Till* <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.L the awrra err operator d th*propaty located at ft above sit*address.hereby autf atDo the rebase of <br /> any and all resul6,geotechnical data angor arvironnhertraGsde assessawt inbmaon to Gro SW JOvamw COUNTY PUBLIC HEALTH SERVICES FmumNSETrTAL HEALTH Otwstott as soar <br /> as it R available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> PAYMENT <br /> RECEIVED <br /> WN 1 ?, 200 <br /> SAN dOAOUINCOUNTY <br /> PUBLIC HEALTH SERVICES <br /> "IVIRDNMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED aY: EsIPLOYEEA: p DATE <br /> Assi mTo: \ -u . BL-WYEE#- 22- DATE: <br /> Date Service Completed (d already w pleted): SERVICECODe <br /> Fee Amount �'_' Amount Pa d / , 00 Payment Date O <br /> Payment Type j InvoiceA Check it Oa eceiv By: <br />