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SERVICE REQUEST <br /> Type of Business or Pro erty FACILITY 10 1 SERVICE R QUEST R <br /> G��Icrnc�r LG d 0 <br /> OWNER/OPERATOR BILLRIG PARTY <br /> FACILITY NAME elRv[JDA 4k/,4k/,444 / 1,4/✓AK _Zj,4Q 9A.d 5 7V <br /> SITE ADDRESS <br /> /(6101 stream Number r01mcna4 AM61 Name Typo Su�ls 1 <br /> Mailing Address (if Different from Site Addressl <br /> cm STA zip <br /> S 37 <br /> PNONE#1AP"I LANo USE APPLICATIO"9 <br /> PHONE#Z &T• BOS DISTRICT LOCATION CODE <br />` CONTRACTOR I SERVICE REQUESTOR <br />` REOCIF.STOR BILLING j'ARTv <br /> BUSINESS NAME PIIONE PT. <br /> MAIlJHG ADDRESS 7� [FAx a� <br /> a ~ <br /> CrrY STATE ZIP f5r-38 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busin or authorized agent of carne, acknowledge that all site andlor project speciflc <br /> PUBLIC HEALTH SERVICES EUVIRDNMENTAL HEALTH DIVISION hourly Chafges asscVed ity will be billed to Rie or my business as identified on this form. <br /> 1 also oerUfy that I have prepared this plication and a work to be performed will ba done' ccordanrq Wilk all SAN JoAouul COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: T r,z? ,. <br /> PROPERTY I BUSINESS OwtIEA O l?PERATOR!MANAGE�'-4 <br /> ❑ OTHER ALITIMIZED AGENT <br /> IY hs Au l+c P wrr proal of autllorrsstlan to slpn k nrqu6vd Title <br />` AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any.and ail results,geotechnical data andlor envirOnrnentallSlte assessment into Tnation to the SAN JOAGUIN COLIIITY PUBLIC HEALTH SERVICES EwRONMENTAL HEALTH DIVISION as soon <br /> as It is available and at die same time It is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> -- <br /> COMMEKrs; <br /> JUN 2 9 t <br /> SAN JO/%QLlIN CUUNTY <br /> PUDUC HEALTH FRVIGES <br /> ENVIRONMENTAL HF-AtYH DIWSION <br /> INSPECTOR`$SIGNATURE: CONTRAC'TOR'S SIGNATURE: <br /> APPROVED BY: I EMPLOYEE VOCE DATE; <br /> ASSIGNED To: EMPLOYEE I: �i DATE: <br /> Dale Service Complet (If already completed. SE me Coot:: �� P 1 E��Q_�) <br /> Fee Amount: Amount Paid �"�-9f1� payment Pale & rf <br /> Payment Type Invoice N Check 4 Received By. <br />