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SERVICE REQUEST . Ahk <br />Type of Business or Property <br />�� <br />FACILITY ID# eRVICE REQUEST # <br />9 <br />O ER 1 OPERATOR <br />`57z� <br />BILLING PARTY 0 <br />FA _ <br />E# r �a 'q � )b aT <br />SCFE ADDRESS <br />2 � Steed Nueiber <br />` 1 '� <br />0(ractlon <br />Stred Name � <br />.type <br />Suite # <br />Mailing Address (if Different from Site Address) <br />STATE z'p 5'7J 2 <br />CITY � `i \ � � � <br />$TATrr� ZIP <br />PHONE # i �• <br />q l25 <br />APN # <br />LAND USE APPLICATION # <br />. <br />PHONE #2 <br />SOS DISTRICT _ _ <br />LocAmoN Cbde... * <br />CONTRACTOR I SERVICE REQUESTOR <br />UESTOR <br />�� <br />Bn.11NG PARTY <br />BUWINESSNAME <br />_ _ \ <br />CONTRACTOR'S SIGNATURE: <br />E# r �a 'q � )b aT <br />LNG -RES <br />L <br />v ^ <br />DATE: <br /># <br />/J <br />EMPLOYEE <br />STATE z'p 5'7J 2 <br />BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business ovoorter, operator or authorbad agent of same, admowledge that an site andW project specific <br />Pusuc HEALTH SERVICES Ew RONmENTAL HEALTH DIVISiar hourly charges asserted with Ibis projector activity will be billed in me or my business as iderdled on this norm. <br />I also certify that I have <br />FEDERAL laws. <br />APPLICANT SWATURE:----J <br />PROPERTY/ BUSINESS OWNER <br />17M-17,51 - 1,1 i ; "t, 5 .- . ., ,., . u .. .. - <br />0 ei' <br />� �-w M -N-0 <br />F707 U., ETT <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 4 the ovo w or operator of the property located at the above site address, hereby authorize the release of <br />any and all rw.sutts, geotechnical data and/or environmentallsite assessment infomradon to the SAN JOAM94 COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soar <br />as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />,VS <br />�J <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EupwyEEt <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE:. <br />Fee Amount: <br />Amount Paid Payment Date <br />Payment Type Invoice # <br />Check # <br />