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SERVICE REQUEST � . <br /> (EH 00 61) Revised 8/23/937 f <br /> FACILITY`ID # ' <br /> �ID' <br /> �.- +INVOICE # ©y!/ <br /> +f, BILLING PARTY Y / N <br /> FACILITY,NAME <br /> ' r'S I TE ADDRESS <br /> x ;. FILE C <br /> a CITY S CA ZIP <br /> = i <br /> BILLING PARTY Y / N <br /> `':OLINER/OPERATOR <br /> DBA PHONE #1 ( ) <br /> t V` _ <br /> ADDRESSPHONE #2 ( ) <br /> �'�„"' _ y <br /> i <br /> CITY, STATE. ZIP <br /> APN # Land Use Application # <br /> BOS Dist location Codeir <br /> ! <br /> CONTRACTOR''end/or BILLING PARTY Y / N <br /> SERVICE REQUESTOR <br /> :x d DBA <br /> s � . <br /> M1�iLING'ADDRESS" � < <br /> ,p C� r <br /> 'CITY <br /> STATE Z11 �/ . <br /> .>> <br /> } <br /> CLING:ACKNOWLEDGEMENT: •1, the undersigned owner, operator or agent of sam � T � n x" { project spec�ftc , <br /> PHS/EH6 hour l charges associated with this facility or actiVity will be bel. BILLING PARTY on <br /> Y: C ` <br /> Page.1 of, this`forma. yy <br /> N h9� L SAN <br /> 4' <br /> I,also"certify that a have prepared this application and that.the work to b ? £ <br /> ,IOAOUIN COUNTY Ordinance Codes and tandards, State.and Federal Laws. ED <br /> jePLICANT S. SIGNATURE'S T fJ�� <br /> Date: 1 e� JGAUIN GtiUhiTY' <br /> y G HEALTH SERVICES <br /> (ENTAL H%TH Dk <br /> . ;AUTHORIZATION TO RELEASE INFORMATION: In addition to'theabove, when applicable, <br /> the <br /> "t: r agent off sam , <br /> property located at the above site address hereby authorizethe`release of any and all results,:geo a hnical data and/or <br /> ernrironmental/site assessment.information to SAN JOA4llIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is avaiLabile,.and at the same time,it is.provided to me or my representative, <br /> Nature of Service Request: Service Coda <br /> �`�" vim" vpp v' <br /> 1` Employee # Date <br /> .Assigned to <br /> Date Servlce.CompLeted / ��_ Further Action Required: Y / N ., PROGRAM ELEMENT <br /> r ;.Fee Amount ,::" Amount Paid Date of Payment, Payment Type Receipt # Check # Recvd By <br /> - <br /> r <br /> CS SUPv UN[T�CLK ���� ,. <br /> FEREHST <br /> s�� <br />