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J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID K SERVICE REQUEST <br /> e/it,, l� I 'R�� IS a0`-936 . <br /> OWNERI PERATOR / N o e BILLING PARTY <br /> FACILfTY NAME <br /> V-2—" <br /> f" <br /> SITE ADDRESS 514/) Ori <br /> Mir <br /> Mailing Address (If Different tram Site Address) <br /> CrtY ' STATE ZIP <br /> PHOHE91 E`T- APN# LANG UsEAPPLICATION9 <br /> ( ) <br /> PHONE 92 a*• BOS DmTFxr LocAmN CODE: <br /> n COKMCTORI SERVICE REQUMOR <br /> REQUESTDR /� / / /// BLLIII/G PARTYVI <br /> ' <br /> I'/ /✓ p� J'N/ p r <br /> BUSINESS NAME / _7_, <br /> C/o Ci oVl S V G I I O PHONES,28...13 • OO(J .. <br /> MAwNoAoDREss <br /> CITY SrATEU ZIP e-lq 0�3 C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, adziowledgo that ad site ardor peajod spedfic <br /> Pueue HEALTH SERvus ElNeLu"jaAL HEALTH DNM*N hourly drarges assOdaled with Ova projector aah*will be billed to me or my business as)denWied on dus hYn. <br /> (j1 alw caruy that I have prepared No app4cabon and that Ne wgrk to be pedomted will be done in a=danm with aC SAN JOAO.M Coutm Ordoanoo Codes.Sfanft"STATE and <br /> FEDERAL laws. � q <br /> APPLrAHr SIGNATURE: � '`"L QATE. <br /> PROPERTY I BUSINESS OwnER ❑ OPERATORI ❑ OTHMAUHORMAGENr <br /> 1AP1uwiG net ew BW PAM.PrUd Of NOO&A000 b X" a iflle <br /> C <br /> " AUTHORIZATION TO RELEASE INFORMATION:When appiraGa L CIe awnerdroperabr of the property located at RIe abore site address,haehy audlatae ete Iele6le W <br /> any and as results geotedmK2I data anJfor envionme aVs m assesvne t inlartuoon td the SANJOAQUINCOUtM PUBLIC HEALTH SERACES ENVIROMENTALHM—M Ofns"as soon <br /> as R is avadable and at Ne same thne it is provided to me or my mpresenGtive <br /> TYPE OF SERVICE REQUESTED: <br /> �/f <br /> '�iC(Ai.L / •/a^' „^. �,rq'�,�C � �tYf•.{rT'( ,.1P' <br /> PAYMENT <br /> �7 ?�p��-,,_� I , S „t� ►y <br /> RECEIVED <br /> f"M• .APT' 7'"~ �o+�.)��..5/AIt-/e,C'•_f� <br /> OAR " g^L_ <br /> INSPECTOR'S SIGNATURE: CDNfiSACTQR•$SIGNATURE: •.-°. P, <br /> APPROVED BY: ExKzy.59: e911 DATE: 3 &91V L <br /> ASSIGNEDTO: YEE#. eff� / DATE <br /> Date Service Completed (if alrea completed): SERVKECODE: 5 Z rl-. 'P f E: Zkbl <br /> Fee Amount 1J¢ Amount Paid $ Payment Date <br /> K <br /> payment Type Invoice Check I{b A, Received By: <br /> • Sao i � a---e� �- y- 3�f� � � •, �� <br />