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.... SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST <br /> S(Zo62(.Q 2 q <br /> OWNER I O ERATOR BII!ING PARTY <br /> FAcltm NAME <br /> SITE ADORus _ <br /> / 6 ar.a;on sa,a n,m. T�v. sun.S <br /> Mailing Address (If Differen7fr SiAddress) <br /> CfTY ATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICAT)ON x <br /> PHONE#2 Err. BOS DwRtcr LOCAihON COD7 E <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REciuESTOR BUJNG PARTY❑ <br /> S <br /> BUSINESS N.AJfE PHONE# Eu. <br /> nWW/7G AOORESs � �` � / FAX# <br /> Crrr <br /> BILLING ACKNOWLEDGEMENT: I, the undersyned property or business owner,operator or authorized agent of same, adolawledge that all srle ardor pn4act speci5c <br /> Pusuc HEALTH SERvrCES ENviRoNkeaAL HEALTH ONCSION hourly charges associated with this project or acdvdy will be bled to me or my business as iderrIIfied on this torm <br /> I also certify that I have <br /> pared thiaawbcabon and that the woperfomhed wit be donAN e in accordance with aG SJOAOUrN COt m Ordinance Codes.S/andartla,STATE and <br /> FEDERAL laws. d <br /> APPLiCAKTSrGNAr DATE all <br /> ■ <br /> PROPERTYI 0 OPERATOR/MANAGER ❑ OTH01AUR1ORr1FDAGENT 0 <br /> XAPPLcurris nct Cr BLL"u pzd aimtKvttidon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appicable,L the owner or operator of the property boated at the above site address.hereby aud"tre the rebase of <br /> any and ail resutts,geotechnical data amVor emAronswrtalfsite assessment intormadon to the SAN JoAamr CQuNTY Puem HEALTH SERVES ENvRowAENTAL HEAL—.H DN=N as soon <br /> as d is available and at the same time it is provided to me or my rapmsentabe. <br /> TYPE OF SERVICE REQUESTED: -` <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE CONTRACTOR'S SIGNATURE: <br /> APPROvEo ay: ENPLAY--#. � DATE: D <br /> ASS)GNFDTO: �jJ EYPLoYEE#. ✓`� DATE: <br /> Date Service Completled!/ (rf already completed): SERVICE CODE <br /> t- Am <br /> Fee Amount: � ount Paid � ' Payment Date <br /> Payment Type Invoice 9 Check Received By: <br />