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SERVICE REQUEST Type of Business or Property FACILITY 10# SERVICE REQUEST# vdq/ r,.i r' ZZ-3 — J SLUNG PARTY❑ OWNER I OPERATOR 7� /e%• FACILITY NAME SITE ADDRESS 3� N, I JIn _ • y C, , 0633 Sue.t ` 1 Stmt Numpr otroc'son 1 Mailing A dress (If Different from Site Address) Via. I � CITY STATE T` ZIP -7S-Z-Z.I PHONE#1 err. APN# LAND USE APPLICATION# ( 6 PHONE 92 err. BOS DISTRICT LOCATION CODE. CONTRACTOR I SERVICE REQUESTOR BUNG PARTY❑ REQUES7ORJ� 1',t'C i vn fr, e PHONE# EXT' BUSINESS NAME rC Maul+c ADDRESS - FAX# LP Cm y�► _r_ I�U�t O �CX—� BILLING ACKNOWLEDGEMENT: L the undemigned property at business owner,operator or authorized agent of same, acknowledge that ad site andlor project sceorc PuaLC HEALTH SERVICES EN IRCNMENTAL HEALTH DIVISION hourly dlarges assocsated with this pmied or activity wid be billed to me or my business as Identified on this form. I also certify that I have prepared this application and that the work to be performed wt➢be done in accordance with ad SAN JCAWtN COUNTY Ordinance Codes.Standards,STATE and FEDERAL laws. DATE: APPLICANT SIGNATURE: PROPERTY I BUSINESS OWNER ❑ OPERATOR IMANAGER ❑ OTHER AUiHOREZEDAGENT ❑ Title rf APPLCANr is not Mr BILLING Proof of wtltoriradon to sig"is rew"d AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of any and all resutts,geotechnical data andlor envi onmentalisite assessment information to the SAN JOAOUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time d is provided b me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED SY: ENPLCY<._ff DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVte£CODE: P I E: Fee Amount I Amount Paid Payment Date Payment Type Invoice# Check# Received By: