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SERVICE REQUEST <br /> Type of Business or Pop-�e 'Oi� FACILITY 10# SERVICE REO <br /> /J�fTd � <br /> �O.r�iy/E2 •sE¢UrcB 57A97/sa ar l/ � t <br /> OWNER/OPERATOR w a/ BILLING PARTY$� <br /> 'Z/ Crai ` L <br /> FACILITY NAME / �*ie` �' G(/`�� ��if'(rIG-e �7'1'T/®✓/I <br /> SITE ADDRESSB�UQG• <br /> a/o3 ume dlra en AYtlNam� Pa SuNI <br /> Mailing Address (If Different from Site Addressl <br /> cm S GG� STATE ZIP <br /> L�S' 4-1 <br /> PHONE#'I T� �- APN# LANo USE APPLICATION# � <br /> �9) gg _ 9721 /z�-a8a -L5 <br /> PHONE#2 SOS DISTRICT - LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQIIFSTOII // BILLING PARTY❑ <br /> �� <br /> / �/��! <br /> BUSINESS NAME A /� PHONE# <br /> MAILING ADDRESS4D �a�-��dU� Fax# <br /> CrTY oC T STiT ZIP <br /> BILLING ACKNOWLEDGEMENT: I. the emig ad property usiness owner, operator or authorized agent of same, admbwledge that all site and/or project specific <br /> PUSLIC HEALTH SERVICES ENVIRONMENTAL H TH hourly assocat with this project of activity wit be billed tome or my business as identified on this form. <br /> I also certify that I have prepared this ap lion d at the w be d ne in accordance with all SAN JoAOuw COUNTY Ordinance Codes, Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: 21 0.�J <br /> PROPERTY/BUSINESS OWNER OP QR/MANAGER ❑ OTHERAUTNORIZED AGENT ED <br /> JIAPnx nrnnotde proof of auNasadon b Sign a re Weed Tille <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I, owner or openlorof the property lasted at the above site address,hereby authorize the release of <br /> any and all results,geolechnial data and/or envlrbnmemallsite assessment Ino mation to the SAN JOAOUW COUNTY Pu9UC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time his/provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ac <br /> COMMENTS: <br /> P`yip�/'pp ENy� <br /> AtPE I <br /> APR 61999 <br /> SAN dOA0U1N COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH❑IVIS!(,,. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> ppp '�-' • L--C�� S� <br /> APPROVED BY: tT-y-� E9PLOTEE#. DATE: <br /> ASSIGNED TO: EMPLOYEE#: Ck l ` DATE: <br /> Date Service Completed fif already completed): SERVICE CODE: J �— P! <br /> Fee Amount: fL � Amount Paid �; � Payment Date <br /> Payment Type Invoice 4 Check# Received By: � _ <br />