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SERVICE REQUEST <br /> Type of Business or Property FACILITY iD C SERVICE REQUEST <br /> 7 <br /> Jlv_�ER I OPERATOR Bauuc PARtt 0 <br /> L) nal p L LVCc � esI, S <br /> ACLLRY NAME <br /> WE ADORES <br /> `� SSStr��aLLL"1MMIaJ/ 4 � S r <br /> Railing Address (if Different from Site ddresssl n <br /> b .5 . l6 S oc e or ( 52 <br /> CRY STATE��;�1 LP <br /> Lo <br /> 'NONE XI <br /> Ea. APNO LANo USE APPLICATIONS <br /> � arq -�l>.o � ad al <br /> NE S2 `3x. BOS DISTRICT - - LOGTION CODE <br /> CONTRACTOR I SERVICE RFOUE37OR ' <br /> BLLMIG PARri t] <br /> (101 1E5TOR p, <br /> IUSNESS NAME <br /> WUNG ADDRESS �J 1 /� �f �L �_ .L. r3 FAx9 <br /> ILLING ACKNOWLEDGEMENT' 1. the undersigned property w business owner, operator or authorized agent of same.. acknowledge that all site andlor pmlect spe. fc <br /> JOUC HEALTH SERv¢ES ENvoto+ ENTAL HEALTH DIVISION hourly charges assocaled with this prgea or activity will be ladled in,me or my business as Identified on this dorm. <br /> use owlify that I have prepared this application and that the work to be performed VA be done in ac;ordancs with all SAN JakOWr COUNTY Drrlinarrce Codes.Standards.STATE and <br /> MER4 Laws. <br /> WUCANT SIGNATURE: DATE: <br /> iOPERTYI SUSNESS OMFR O OPERATOR/MANAGER MOTHER AUTHORIZED AGENT ❑ G/V e <br /> NAPn rirrn(RMRahacP.wTitle <br /> UTHORtZATiON TO RELEASE INFORMATION:When applicable.L the ovmer or operator of the property located at the above site address,hereby authorize the release of <br /> Y and as results,geotechnical data andfor envinimm nraYSde assessment inks nUM to the SAN JOACARr CcvRTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEJATH DIVr510N as soon <br /> it is available and at the same tern,it is provided to me ormy representative. <br /> 'PE OF SERVICE REQUESTED: <br /> R'eoet4) 5ur£CtCe [[[[�v�SOY d L COn7QlM7 LClyDrl <br /> )MMEWS: Pe SrdeS <br /> y / 93/–/37S PEGENEC. <br /> 5-35-"S Solari �ancL fc6, R <br /> Sfack+,�h f (2 . 9'5 car s— SEP 2 5 2500 <br /> PUBLI�R�P H p RH OE5StOn <br /> ENVIRONMEN <br /> PECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> PROVED BY7� I EMPLOYEE X: � DATE: <br /> SIGNED i0: 1 Y'� ENPLOTEERV C� DATE: <br /> to Service Completed (I already completed(: ,r _ e SERVICE CODE: '� S I P I E. <br /> I Amount: I i• Amount Paid ' C-C) Payment Date /- Cd <br /> Reeved By: � <br /> anent Type '+`;1.t L� ( Invoice 9 Check 4 3[?l� 4- ,� <br />