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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> �REQUEST <br /> 7# <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> Nl i vop ncp sTcs R--i.,l OC-7 <br /> FACIUTY FUME <br /> L4 LC,5 it�i�L �t7L <br /> SnEADDRESS LI —�� �A17 <br /> ! <br /> OUvc5on MA� SnM Ham. TYv. Suit. <br /> Mailing Address (If Different from Site Address) <br /> i , fL �� M rJ 1 <br /> STATE ZIP <br /> CITY ( • <br /> S'T�Lk.'CDN �jZQ- <br /> PHONE#1 EXT. APN# LAND USEAPPucAwN# <br /> PHONE#L aT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQUESTOR <br /> �J i M 1OPrL <br /> PHONE# EXT. <br /> 8"INESs NAME1�iOD �--I LG�S � �5�- �Cl�1 I I <br /> FAx# <br /> MAILING ADDRES3 _ > � C c'6- Z- <br /> C rTY < ��, \ STATE Ln S,L)7 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of sane. ac$ujuMedge that all Site andfor project specific <br /> Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH UNISION hOurty tis associated vrtUT )ed or acdvity will be billed to me or my business as identified on this form <br /> be a done in aaArdance with a9 SAN JOACuw CouNTY Ordnance Codes,Starxfards.STATE and <br /> 1 also comity that I have prepared this appf all <br /> FEDERALlaxs. <br /> R DATE: <br /> APPLICANT SIGNATURE: ell <br /> PROPERTY I BUSINESS OWNER X OPERATOR/M NVL R ❑ OTHER AUTHORIZED AGENT ❑ <br /> C ApRr wr a x(N BL L r G Pian P'mr of auuwtntlon to sign h rwqucvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address•heretry authorize the release of <br /> any and all results,geotechNcal data arklJor emrironmentaVsite assessment information to Ilia SAN JOAcUN COUNTY Puouc HEALTH SEzvtCES Em-SONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided in me or my representative. <br /> TYPE OF SERVICE REQUESTED: (� <br /> COMMENTS: <br /> jP C lI <br /> (/ PAYME'N7 <br /> RECEIVED <br /> 'EP2 82001 <br /> SH.I\i JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> INSPECTORS SIGNATURE: CONTRAGTDRas SIGNATURE: 4ONIAENTAL HEAL <br /> APPROVED BY: �, EstPLOY`a1-. �-� DATE: <br /> ASSIGNED TO: <br /> EHPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> SEPI—CODE � (. PtE.? (j:3 <br /> Fee AmounL' ( j iJ Amount Paid ,� 3 Payment Date Cj I Q/6 <br /> Payment Type Invoice 4 Check 4 6��q LZ Received By: <br />