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Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# <br /> � � <br /> SERVICE REQUESTIl# <br /> OWNER/OPERATOR P-/� I �l�,J r7 O <br /> BILLING PARTY 0 <br /> FAciuTY NAME <br /> SITE ADDRESS / 9son al <br /> StrtttNumb�r OlretGan Stn tName <br /> Mailing Address (If Different from Site Address) Type <br /> i 3t 1�2 s. <br /> cmr <br /> 5C Iq UY� STAT ZIP <br /> PHONE#1 Ewa. ��J L <br /> APN# LAND USE APPLICATION# <br /> PHONE#2 *. BOS.D DlsTwcT <br /> +, LOCATION CODE <br /> •,ri , <br /> :r3 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR _ <br /> BUING PARTY 0 <br /> BUSINESS NAME <br /> 3 r— PHONE# .2/y / E; <br /> ADORESS <br /> ( rd Z S. ���� � � �n ��- <br /> MAILING <br /> FAx# <br /> CITY 9 A s,,�6 --5 03 <br /> STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned 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 hourly charges associated with this project or activity will be billed to me or my business as iden0ed on Lhts form. <br /> I also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOA .1 COUNTY Ordinance Codes,Standards.Si and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: �( /-�� <br /> —/ DATE. <br /> PROPERTY/BUSINESS OWNER ) OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 � <br /> / If Avax wr is not UxI Q un c Parry Proof of jufhwiiatlon to sign Is ruquirod )-i f I o <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property bcated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsile assessment information to the SA14 JOAOUI,4 COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIvlSlou 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 /> COMMENTS: <br /> A/0"�d' <br /> 411" L <br /> INSPECTORS SIGNATURE: 1" 6 O <br /> CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: Z9 DATE: <br /> DATE: D f <br /> �J Zip <br /> ASSIGNEDTO: Q- EMPLOYEE#: DATE: �y <br /> :Date Service Completed (if already completed): / (/ <br /> SERVICECODE: PIE: „`�a�'..;. <br /> Fee Amount: Amount Paid <br /> Payment Date 't <br /> Payment Type Invoice#' Check# <br /> 1� ` Received IIy: <br /> ��� - 2- y-, ' j t <br />