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W <br /> ' SERVICE REQUEST <br /> !Typ, f Business or Property FACILITY ID# SERVICE REQUESTx 1 OPERATOR BILLING PARTY❑ <br /> a� F <br /> FACIUTYNAME QA ' <br /> SITE ADORESS <br /> �• spa., <br /> Mailing Address (If Different from Site Address) <br /> I �- a <br /> Crrr � STATE S / <br /> PHONE91 EXT. APN# LANDUSEAPPUCATION# <br /> 0 . <br /> PHONE#2 aT• 805 DISTRICT LOCATION CODE- <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RzQUESTOR BILLING PARTY❑ <br /> BUSINESS NA*E , PHONE It 9xr. <br /> 1�fr' �i. U-)m-', <br /> ADORE= n FAx# <br /> CITzip <br /> Y <br /> L 1 STATE <br /> t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, admaoriedgo that all sde andlor project specific <br /> Pueuc HEALTH SERwcEs ENvatcw cENTAL HEALTH DIv=N hourly dtarges associated wish this pro)ed or activity wig be breed IQ me or my business as identified on this toren. <br /> I also cortily that I have prepared this application and stat the work to be performed will be done in acwnlance with all SAN JOAam COUNTY Ordure=Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLnANT SIGNATURE: , �� m+ DATE: <br /> PROPERTY IBUSWESSOWNER ❑ OPERATOR IMANAGER ❑ OTHMAUTHORREDAGFNT ❑ <br /> 1AWLc-vrisna4*0turcPwn Prao(afmomezawnto34Mismq.* d Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appkable.I,Me owner of operator of the property located at the above zits addmis,hereby authoAw the rebase of <br /> any and all results,geotechnical data a"or eavironmentallsite ass83srrleflt inionttatbn to the SAN JoAojw COUNTY Pueuc HEALTH SERvICEs Er n"AENrx.HEA,H DNISIW as soon <br /> as it Is avaitable and at the same Itme it is provided to me or my represattativa. <br /> TYPE OF SERVICE REQUESTS➢: / <br /> /`- e ul <br /> COetr�tErrrs: <br /> ?AYMENT <br /> RECEIVED <br /> t •11 u0 �� <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED Eff V\-. tZYEE <br /> 11: r f <br /> ASSIGNED To: �� # -� DATE: aZ <br /> Date Service Completed-(rf already completed): SEIC"XCODE: PIE- <br /> Fee Amount: .v� Amount Paid �� Payment Date ,? $ OZ <br /> Payment Type 4`L, Invoice fk Check# Received By: <br />