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i <br /> `. <br /> SERVICE REQUEST <br /> NFACI <br /> Business or Property FACILITY 10# SERVICE REQUEST# <br /> OPERATOR �� <br /> BILLING PART*X <br /> N [/ �/� <br /> GJ I V 15t <br /> SrTEAADDRESSSS <br /> A—+4 StreetNumbv TYPe SuiteA <br /> Mailing Address (If Different from Site Address) <br /> C SrnT <br /> YDl <br /> ZIP <br /> PHONE#1 E". 7A` <br /> N# LAND USE APPLICATION# <br /> PHONE#2 W. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REOUESTOR <br /> REQUESTOR <br /> law BILLING PARTY❑ <br /> BUS E S IrAME PHONE# Exr. <br /> Mwluf,GORE f <br /> G E 'f (i f/Ay FAX# <br /> m) 42 2� <br /> CITY I ,�r� STATE CA LP c)52 <br /> 4 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that afi site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me Or My business as identified on this torr. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAGuw COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: <br /> DATE: I <br /> PROPERTY BUSINESS ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> YAPKrAmris nor rhe kUM PARr, proof Of sulharizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE IN FORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnicai data andlor environmentallsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: <br /> iy <br /> .i <br /> 2000 <br /> �NV1 <br /> 11 <br /> 0;7A44 elp�r A oH u' <br /> INSPECTOR'S SIGN /ATURE: �.t~ CONTRACTOR'S SIGNATURE: prVEsrON <br /> APPROVED BY:. 4,V-41 <br /> � 1 r � EMPLOYEE#: DATE: <br /> d <br /> ASSIGNED 70: fi EMPLOYEE#J': D�� DATE: _ <br /> Date Service Completed (if already completed): SERVICE CODE: S-- I.P f E; <br /> Fee Amount: - Amount Paid S I Payment Date -L ra <br /> Payment Type ✓ Invoice#' Check# 7-'13-7 p Received By: <br /> r <br />