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SERVICE REQUEST
<br /> I Type of 8,:Qsiess or PPrropertty,�(1 FACILITY 10# ;.:..' SERVICE REQUEST#
<br /> r
<br /> OWNcR I
<br /> OPERATOR
<br /> � :Lr„w. i x. BIWNG PARTY
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<br /> fFAC,LTr NAME t,
<br /> SfTE ADDRESS ,
<br /> P. sem,
<br /> rr. hlailing Address (If Different from Site Address
<br /> STATE ('t A
<br /> PnvhE V. L� 1 ExT APN# LAND USE APPLICATION 9
<br /> r✓ PHONE r`2 ` 11Q FST. BOS DISTRICT !y LOCATION CODE,
<br /> CONTRACTOR/SERVCE REQUESTOR-.: 4....:
<br /> r RECUESTOR BtwNG Palm
<br /> BUSINESS NAME Q ONE# EXT
<br /> M,juNG ADDRESS FAX# I
<br /> .r C'--y STATtC t, ZIP
<br /> EILL!NG ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authortmd agent of same, ac8nowtedge that a8 site and/or project spec,-)c
<br /> SERVICES EYVIRON4ENTA.HEALTH DWiON houdy dmarges associated with this project or acdvity wia be bW bo me or my business as identiited on this form
<br /> �„ z:so xr`f at t tmave prepared this application and that the wodt to be performed vA be done in accordance with 9A SAN JOAQuw COUNTY Ordinance Codes,Standanjs SYAiy
<br /> a-7UCAh7&GliAr--RE: !l /1—x—— (DATE: 7.
<br /> SUSL4ESSOWNER t❑ OPERATOR/MANAGER ❑ OTHERAIIiHORIZFDAGENT. '. , ❑
<br /> #APp[Xurisn4rtlN8LLNGpradofwAled d-tosigghrsquitd.:... r;u.
<br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner oroperatorof the property located at the above site address,hereby authorizeCme release of
<br /> r.y arc zl resufts:geotecnmcal data an(Uor environmentaVsite assessment informatlon to the SAN JOAouw COUNTY Pusuc HEALTH SERvms EwaoNA*NTAL HEALTH DrnS)ON as Boort
<br /> as. s ava.'aCie anc at the same time itis provided to me or my reptesentative, .
<br /> T'fPEOF SERVICE REQUESTED:
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<br /> am U1sPECTOR's SIGNATURE ''v'. CONTRACTGRr3SIGNATURE:`'
<br /> APPROVED sY: EIIPLQYEaI: t`.t,:” :3"':. ATE; :e
<br /> ASSIGNS T0: "9 t s..r.1i.i ' =
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<br /> EMPLOYEE#:' };;"�m J!`?;+,: 'DATE::.,-1,v:?;>i�{fS.;!»,. r'y'a•;•.,,•. ;(•:'• •,'.
<br /> mmr Date Service Completed (if already completed): + ,' �' ? +;;a<:; •SERWZCOOP:; ':` t ^;•;� P,I'E
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<br /> Amount
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