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SERVICE REQUEST <br /> Type ofyBuusinessssororr Property FACILITY ID# tVICE REQUEST# <br /> V /—G/ BILL NG PART.04 <br /> OWNER I OPERATOR PART. <br /> 04- <br /> NAME G �y� <br /> S[TE ADDRESS Suite t I <br /> 195735-5- <br /> 9 57c7j 5-5— Street Humber Okeciion N . <br /> Mailing Address (if Different from Site Address) <br /> /y ] <br /> STATE <br /> CITY <br /> PHONE#I APN# LAND USE APPUCATtON# <br /> ( <br /> e-[ �. LOCATION COD@- ,- - <br /> PHONE#2 <br /> 70$DfSTRICT'. - <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RE4UESTOR BILLING PARTY 0 <br /> PHONE# <br /> BUSINESS NAME <br /> MAIUNG D SC, �./ ) F II` <br /> cJ y f STATE ZJP GJ '15 5 <br /> f <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agerrt of same acknowledge that ail site ardor project specific <br /> PUBLIC HEALTH SERVICES EWRONMENTAL HEALTH DlvLstoN tlourty charges asrocia�d with this project or activity will toe billed to me or mry business as identified on this form. . <br /> I also certify that I have preps riicarion a to be rm a accordarice with all SAN JoAam Coumy Ordinance Codes.Standards.STATE and <br /> FsoFRAL laws. - , 4 <br />[ DATE: <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER Q OPERATOR I MANAGER 0 OTHERAUTHORIMD AGENT <br /> YAPPLICW is ra ft axuaa PAa�ry mod of xoxizmftn to sign is requuadd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1.the owner or operator of the piopeity located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data ardor enveonmenrallsite assessment Wonnatian to the SAN j0AQUIN COuNTy Rmuc HEALTH SERVICES EW RONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time 9 is provided to me or my representative. <br /> TYPE OF SERME REfluwmo: <br /> INSPECTOR'S SIGNATURE: CONTRACTOWS SIGNATURE: <br /> it APPROVEDSY: EPLOYEE# DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> ' Date Service Completed {if already completed): SERVICE CaOC P 1 E. <br /> :? l Fee Amount: Amaurst Paid Payment Date <br /> ..A <br /> Paymen#Type t invoice# Check# Received y: + <br /> ., <br /> t <br />