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SERVICE REQUEST <br /> Type of E3usincss or Property FACILITY ID k <br /> SERVICE REQUEST" <br /> OWNER/OPERATOR _ i\ ! <br /> BILLING PARTY(X <br /> FACILITY NAME T— <br /> � ` `0\N-el ' 0,4 vin <br /> SRE ADDRESS Ll <br /> ✓ � so-..t x„mD., oa�o� 1 ��y� Zo n <br /> Mailing Address (If Different from Site Address) M x� <br /> TrD•CITY s•x.e <br /> � d . S7 <br /> STATE �[ <br /> PHONE AIEXT- APN# vP ^�6 <br /> Cj ��� —a /_ I a e �7 LA' <br /> USE APPLICATION )- `3 ,9s- <br /> PHONEfiZ [ CSV I l/�J 7_ �( f �0� rE dGYI S-I4f11 tl' <br /> Esr. BUS DISTRJCT -- <br /> I.00ATION CO <br /> REcwESTOR <br /> CONTRACTOR/SERVICE REQUES70R <br /> UIVG PARTY Q <br /> QUSIttESS NAVE <br /> PHONE 0 EXT. <br /> MAILTNG ADDRESS <br /> FAx x <br /> CITY Lou <br /> STATE /t� z,P /,? <br /> BILLING ACKNOW!EDGEMENT: 1,the undemigned property or business owner,operator or authorized agent of same,adcrrarrtedge Ihat6atf site arrdlor project specfic <br /> Pl1RUC fiF�tlTtt SERVICES ENVtRONttENTA1IiEALTTf DMSIOtT hourly chargC;as;ocialed with this project or activity wl!be billed to me or my business y idenliGed on th4 foam <br /> I also cc!'*tial I have prepared this appric Zion and that the work to be performed wil be done in accordance with all SAN JoAOUW COUNTY Ordirancn Co*--.Slandanis.STATE and <br /> FEDERAL laws- <br /> ,r ` r <br /> APPLICANT SIGNATURE: ! l� <br /> OV W` DATE: t/Y- •• Il <br /> PROPERTY/BUSWESSOWNER 0 OPERATOR/MAXAGER 0 OTHERAUTHM7EDAGENT <br /> WAvrrr-wriznot pte — SC(� A►L( <br /> P�nrY P�f of auilwizadon to sign a rxturrvd TWO <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owncror operator of The property located al the above site address,hereby authorize the release of <br /> any and a0 results.geotechnical data and/or environmenullsile assessment information to the SAN JOAOUW COUNTY PUBLIC HEALTft SERv10ES EWRONW-NrAL HEALTTI DtvistOtt as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REOuESTEO: <br /> N�t�ufi� C0 f s` y <br /> COMMENTS: •�=�� ��� ►'S ��� �o r ly�-S <br /> Sc�c e c`v _� V,edpa <br /> 1�i p--L ems c` ``� c� - — 1360 <br /> 1.2 <br /> rte�^ <br /> INSPECTOR'S SIGNATURE: ll/Q C:flf'►v►'`a"^�' � , <br /> t/{,^ �RTOR'S SIGNATURE:TM 3 <br /> APPROVED DY:, <br /> EMPLOYEEA: l Z g DATE: <br /> -ASSiGNED70: TV1 <br /> EMPlOYEEfI: -I 3�� .DATE: <br /> Date Service Completed (if Iready completed): <br /> FCC Amount: Amount Paid _� <br /> ' SERViCECODE ,j�. <br /> (� PIE: 6 02, <br /> �i <br /> y S_ Payment Date I Z <br /> Payment Type !i Invoice#' <br /> b <br /> Received By: <br />