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T * 0 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> F*�o © 6oo �Z 123 <br /> OWNER I OPERATOR BILLING PARTE❑ <br /> FACIUrY NAM (� <br /> o� J Wt ' <br /> SITE ADORESS <br /> TV- <br /> Mailing Address (If Different from Site Address) <br /> CrrY STATE ZIP <br /> PHONE#1 UT. APN# LAND USE APPIJCATION» <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BIt JNc PARTY❑ <br /> BUSINESS NAME PHONE It m�cr <br /> MAILING ADDRES FAX 9 <br /> t7 <br /> Clrt STATE ZIP _ <br /> C4 1 Z <br /> BILLING ACKNOWLEDGEMENT: 1, the undersgned property or business owner,operator or authoraad agent of same,advmowiedgo Vmat all 3r1C and/or project specific <br /> Puauc HEALTH SERvrGEs EwRf.tiI.F TAL HEALTH Drvr"hourly charges associated with Mie project or acgyq will be earned W me or my business as identdied on demi bra <br /> I also certify that 1 have prepared this application and that the work to be performed wiz be doom in aowrdanco with a4 SAN JOAQM CWM Ordwance Codes,Standards,STATE and <br /> FEDERAL lawn. y��� <br /> APPUGAHT SIGNATURE;4�� )/ ,,g&c , Q/J� DATE: 2i <br /> PROPERTY IBusu+ESSOWNER ❑ OPERATORIMANAGER or OTHMAUntORaEOAGEKT ❑ Sinisr inr- �v/I�1 �_1 d ' <br /> YAPPVawrisnorfhrffLLMprod dwtwh3d nroSvcisMgLww V Tltf• <br /> AUTHORIZATION TO RELEASE INFORMATION:When appkable,L Me owneroropeator of dw property boated at the above site address,hereby authorize the rebase of <br /> any and all results,geotechnical data an llor environrenWsb assessment information to the SAN JOAO=COUNTY PUBUc HEALTH SERv)cEs ENvaoNmAEwAL HEALTH Omsm as soon <br /> as it is available and at the same UrA is prorided to me or my n4nserlattve. <br /> TYPE OFS ICE RE0U <br /> 1 <br /> COMMENTS: ^�-- I 6— <br /> [D) zr <br /> -,� <br /> /a,-, <iQ -rJ MAR 2 1 2002 <br /> ENVIRONMENT HEALTH <br /> PE�iMIT/SERVICES <br /> INSPECTOR'SSIGNA E: CONTRAcroFesSIGNATURE: <br /> APPROVED By..• LL EYPI.OY`aff: DATE: Q <br /> ASSIGNED TO: . EMPLOYEE#: DATE: <br /> Date Service Completed-(if already completed): SWOCECODE. 7 -p I E O <br /> Fee Amount: C Amount Paid Payment Date l/ <br /> Payment Type Invoice# Check 9 Received By: <br />