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tf <br /> tiC SERVICE REQUEST <br /> Type of Business or Property. FACILITY ID# SERVICE REQUEST# <br /> c.0 7u rz.a 2.56 <br /> OWNER I OPERATOR 01 1 BILLING PARTY❑ <br /> l� Ore—,- 1HOvu 05 <br /> y FACIL"NAME <br /> SITE ADDRESS s I T-C 4 j<L It- <br /> 1.544- 4 <br /> Rf� <br /> Stmt Numbs mfedon Street Acme Type Suites <br /> Mailing Address (If Different from Site Address) <br /> COY Iv�C� STATE ZIP <br /> Aq33 <br /> PHONE#1 Exr• ��PN# � • -" LAND USE APPLICATION# <br /> PHONE92 ExT• BOS:DISTRICT LOcATIOl CODE'. <br /> CONTRACTOR/SERVICE REQU ESTOR <br /> REOUESTOR BILLING PARTY <br /> (26J <br /> BUSINESS NAME PHHONE# <br /> MAILING ADDRESS FAx# <br /> cox -F>7 ( ) <a <br /> CRY c r/ STATE CA Z]P �r <br /> 30 <br /> BILLING ACKNOWLEDGEMENT: 1.1 ` <br /> theundersigned.property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION houdy charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared chis i bon and that w I performed will be done in accordance with all SAN JOAOUtN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. �j <br /> APPUC.AHT SIGNATURE: DATE: J Xe z_ <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MWGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLCMTh rwf the AATY proof of authorfzitfon to 31gn Is requfr- ritta <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 an results,geotechnical data andfor env4onmentallsile assessment information to the SAN JOACKWN COUNTY PUBLIC HEALTH SERVICES ENvtRONMENTAL HFALTH DmSION 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: <br /> 2 G� 11JQ S' GfI2 f{C, GONTA 'l�'Nr�Tlorll g; P02T <br /> COMMENTS: <br /> PAYMEfv <br /> REGONE1 <br /> AAR u 9 <br /> ;AN JC)AUUIN U(,UN <br /> INSPECTOR'S SIGNATURE. 0 ONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: ( 9 1(. DATE: L I <br /> ASSIGNED T0: EMPLOYEE#: a7(� [� (� DATE: 2 <br /> k V 1 J <br /> Date Service Completed (if already completed): SERVICECODE: a P I E: a b <br /> Fee Amount: Amount Paid Payment Date 3 Z f <br /> Payment Type { °t Invoice#' Check# Received By: <br /> to <br /> 6 r, ` <br /> r(�u m t vi Via/bit A <br />