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i s <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID tf SERVICE REQUEST# <br /> /Y A L <br /> OWNER OPERATOR 131LUIIG PARTY 0 <br /> FAOILITY NAME <br /> VA IV <br /> srfEADORESS �rA W iY V <br /> 74-,63 SEWN thyw t>�� ssreaL <br /> Mailing Address (If Different from Site Address) <br /> � <br /> CITY LT-O G D/V STATE CA ZIP -I d s-Z I <br /> PHONE#11 APN# LANDUSEAPPucAToN# j <br /> PHONE#2 BOS DISTRICT LOCA N CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> Bw_wG PARTY <br /> REQUESTOR <br /> BUSINESS Decr.AME <br />" PHOHE# S <br /> MAjuNG ADOREss FAX# <br /> o . Box .37q4- <br /> CITY <br /> 7 4- <br /> CITY LO STATE ZIP 9 S-3 0 r <br /> I <br /> BILLING ACKNOWLEDGEMENT,"I,the undersigned property or business owner,operator or authorized agent of same, acknowledge Chat all site andlor project speahc <br /> PUBLIC HEALTH SERVICES ENVIRONLIENTAL HEALTH Orvism hour)charges associated with d is projector acti%*wil be trilled to me or my business as identified on this form <br /> i also carafy that I have prepared osis Iication and a wank to be performed will be done in acwrdance with all Sora JOAOUIN COUNTY Ordnance Codes,Standards.STATE and <br /> FEDERR&laws. lf / <br /> APPLICANT SIGNATURE: DATE: �J /3�J O <br /> PROPERTY/SUSINESS OWNER 0 OP ERATOR/MWGER 0 OTHFRAuwRaEDAGENr <br /> CAPPGr�urranottheE11yGPMr!pmvfrfaLrrt=tmdorrtosign ismq o Title <br /> AUTHORlZATiON TO RELEASE INFORMATION:When apprirabk41.the owner or operator of the property located at the above site address,hereby authorize the retease of <br /> -any and all results,geotechnical data anWor arrAwmentaVsite assessment information W the Sm JOAouw COUNTY PUBLIC HEALTH SERVICES ENVIRONteaAL HEALTH DIVISION as soon <br /> ti as it is available and at the same time it is provided to me or my representadve. <br /> TYPE OF SERVICE REQUESTED: l <br /> OIL c E/V <br /> COMMENTS: <br /> IN <br /> n� SAN J:JAOU.i,'GQ''NTY <br /> P'JBLIC':'P,'LT,S'RV'.^ES <br /> INSPECTOR'S SIGNATURE: 3W ComrRwroies SIGNATURE: <br /> APPROVED BY: i Fa1Pl^"Y W f�: DATE: (, grjol <br /> AssIGNEDTO: [ EMPLOYEES: DATE: ` <br /> Date Service Completed (rf already completed): SER=CODE: 'l.�(�. P I E:. <br /> Fee Amount: Amount Paid �•� g _ Payment Date <br /> i' <br /> Payment Type ,/ invoice 9 Check 0 )33—I Received By. <br /> 1 <br />