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SERVICE REQUEST <br /> Type of Business or Property FACILrrY ID# SERVICE REQUEST# <br /> O <br /> 1 �� <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> r– oA <br /> SITE ADDRESS—7-,7 �� f �,. F 0 N AP\ S l7 <br /> so-.am.ne.. otn se.ecnae Ty" &fto <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE ZIP <br /> ;�,7 - i:� <br /> PHONE#•I EXT. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 BW DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARIK <br /> BUSNESS NAMEPHONE# <br /> _ N l X35 -- Z <br /> MAILING ADDRESS FAx# <br /> �0 5 s " <br /> CITY C v STATE F- LP 5 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authortmd agent of same,adaawiedge that al sde andlar project specific <br /> PU&C HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly dupes assaaated with this project or ac hrity will be bred to me or my business as idended on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with ad SAN JOACAM COUNTY Orainame Codes,Sbrderft STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSNESS OWNER ❑ OPERATOR I OTHER AUTHORIM AGENT ❑ `ZO J G— C-, <br /> MOPM.wristaffw pmdofAw rfadwtosipisnqu"red title <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable,L the owner or opuator of the property boated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data arxUor envronmentaltsde assessment information to the SAN JOAOUN COUNTY PUBLIC HEALTH SERVICES EWPONME NTAL HEATH ONWON as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE RFWESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EsOwYnat DAT-' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SEtvICE CODE: P I EE <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice 9 Check# Received By. <br />