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~" SERVICE REQUEST `!F <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5- C) <br /> OWNERI OPERATOR BILLING PARTY❑ <br /> FAcnm NAME <br /> SITE ADORE ' �,{ <br /> �en `' O — '` street Nan. T S�Nrt <br /> Mailing Address (If Different from Site Address) <br /> Crry STATE ZIP <br /> PHONE#1 APN# LANDUSE APPLICATION# - <br /> ( oo - - <br /> PHONE#2 FAT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> Fit <br /> OUESTOR BILLING PARTY❑ <br /> ZACA—IKLY c_ wcuv <br /> sn1ESS NAME PHONE# <br /> WW6 •fS-GILAy151� 41�a-001 ( <br /> ILRIG ADDRESS FAX# <br /> 45-i0 ft3om6- PAY- �fL. SvIY� 4 Yo'0135 <br /> Y lslawf r STATE Ck LP cts-uq <br /> BILLING ACKKNNOWWLLEEDGEMENT., I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that al site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsiON hourly charges associated with this project or ac5vity will be billed tome or my business as identified on this form. <br /> I also certlfy that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAanN CouNTv Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. .�,�/�I,,a-., <br /> APPLICANT SIGNATURE: C/S, `wU7/ �� WCL3`Y/ DATE: I—Iq'OI <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORRED AGENT EfGMLELQIHG�(- <br /> ff AAPrFivrisrolftBc+c Pum Proof ofauNairarlon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operatorof the property located at the above site address,heretry authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAA JoAWIN COUNTY PUBuc HEALTH SERvicEs ENVIRONMENTAL HEALTH DNIstON as soon <br /> as it Is available and at the same time it is provided to me or my representative. - <br /> TYPE OF SERVICE REOUESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: ' 1 DATE: <br /> ASSIGNEDT0: �tOL LV\.V <br /> EMPLOYEE 3 DATE: <br /> .Date Service Completed (if already completed): SERVICECODE: P/E: 26Ci( <br /> Fee Amount: 17 OD Amount Paid Payment Date <br /> Payment Type Invoice#' Check# Received By: <br /> 14S 60't'i" .4y <br />