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SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 6� 0o a$5 � OWNER/OPERATOR BILLING PARTY❑ FAcRfrY NAME SITE AOORESS SbM NwMr drectlon � � \ SO'�t Nyn� �l �"'� 1Y0� StrNt Mailing Address (If Different from Site Address) CITY STATE LP PHONE#1 W. APN# LANG U5E APPLICATION ( ) PHONE#2 BOS DISTRICT LOCATION CODE- CONTRACTOR I SERVICE REQUESTOR EQuESTOR BLUING PARTY❑ BUSINESS NAME PHONE# MAILING ADDREss FAX R 7 10 (-( :/d A, / (Q^- CITY Z STATE 'rte BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, atlmowledge that all site andfor project specific PUauc HEALTH SERVICES ENVIRGNwEwAL HEALTH Ovistom hourly charges associated with this project N actvty wm be billed to me or my business as identified on this form. I also certify,that I have prepared this application and that the work In be perfonned will be done in accordance with ad SAN JOAGIIw COUNTY Ordinance Codes,Standards,STATE and �yg FEcERAL laws. APUCANr SIGNATURE: \fes. // DATE' D2— PROPERTY/BUSINESS OWNFAy ❑ TOR/MANAGER 0 _�- -OTHER AUIHORRED AGENT ❑ ITAPPUtJNr Ml thi,Bw�cPwrr.prodofauthwtudon to sign a required Title AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner car operator of the property located at the above site address,hereby author®the release of any and all results,geotechnical dam ani./or emkonmental/sfte assessment infvmation to the SAN JOAGUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same tune it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Ju t lll� � COMMENTS: INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED try: - it E!APLOYrIf. —�/ DATE: ASSIGNED TO: ) EMPLOYEE 0. , DATE: Date Service Completed ('rfalready completed): - SPRVICECODE: _7777—F P I Et 2G 99, Fee Amount Amount Paid Payment Date n Z Payment Type Invoice# Check III Received By*