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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST it <br /> e4 ' �s�e wr�s� S/�Oa '3,1 <br /> 3 <br /> OWNERI OPERATORvi. / �O�'!��/ • Bw.wc ARrY❑ <br /> FAOmmflAME <br /> 53 00RE�• <br /> m. sva.a <br /> Mailing Address (If Different 1prn Site Addre I <br /> CITY -5,r 12 �DS - soi ZIP <br /> PHONE#1 En. APN# LANDUSEAPPLICATION# <br /> 0) 01 - 331 <br /> PHONE#2 BCS DISTRICT - Lowic�im C+�oorEC ;' <br /> 7't - <br /> CONTRACTOR ISERVICE REOUESTOR <br /> REQUESTOR J� / _ ,p/T�• BALING PARTY <br /> BUSINESS NAYGE'±G "On� /J �h� PHO �* <br /> MAWNG ADDRESS /[--7 n� �. ✓1 �//S �/ FN4o 2 1 <br /> CITY ,S'p/yIC J T�YD�� /! STATE Y/� LP <br /> BILLING ACKNOWLEDGEMENT., I,the Undersigned property or business owner,operator Of authorized agent of same,acknowledge that at sHe ardlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONAFNTAL HEALTH Donsm hourly charges associated wilh this projector actvity will be trilled to me or my business as identified on this loan. <br /> I also cardy,that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoACuw CGuNrY ONfnence Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLIGAmT SIGNATURE: <br /> PROPERTY/SUSWESS OWNER CPERATCR I MANAGER JZ, CnmRAUTHORIZED AGENT ❑ <br /> 11APacwTsmtft9su1cPAm.pmdalwtw•lntfon wsign Is mwired Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,L the awner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data 3MVor eavironmentallsite assessment Information to the SAN JOAOUN COUNTY PUBUC HEALTH SERVICES ENvwONYfNrAL HEALTH DN=oN as soon <br /> as ft is available and at the same time it's provided to me kr my repr ermtatim <br /> TYPE OF SERVICE REQUESTED: UAJ S.J <br /> COMMENTS: I V - PAYMENI <br /> RECEIVED <br /> AUG - 2 M2 <br /> pUBLICOHEEALTH S RNCES <br /> -wAK'NAhFtJlt41 HEALTH DIVI8IDN <br /> INSPECTOR'S SIGHATUR CONTRACIOn's SIGNATURE: <br /> APPROVED ay: P1 EMPLOY--#: ��. DATE: Q y <br /> ASSIGNED To:J/21 _ EMPLOYEE#: j DATE <br /> -.Date Service Completed (rf already completed): SERVICECODE <br /> Fee Amount -7)i 2 Amount Paid Payment Date <br /> Payment Type Invoice# Check Received By: <br />