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a® I II Type of Business or Property OWNER 1 OPERATO FACILITY NAME SITE ADDRESS / umgK dlr Mailing Address (If Different from Site Add ss) SERVICE REQUEST FACILITY ID R Crry PHONE r91 A P N TBQSDW�R>cT PHONE n2 f CONTRACTOR I SERVICE REQUESTOR REQUF.STOR BUSINESS NAME --- SERVICE REQUEST BILLING PARTY 3 ,--' A/ I Tro. I sm11 s STATE ZIP LAND USE APPLICATION k I LOCATION CODE BILUNG P EFT. FAx MAILING ADDRESS�J O ��' � ,! ` STATE /y`� ZIP C TTY C 7 er, operator or .--ed agent at same. acknowledge BILLING ACKNOWLEDGEMENT: I. the undersigned property or business ownthat all site and/or project specific PUGLrc HE41ri SERvICEs ENVIRCNMENTAL HEALTH ONIs;cN hourly charges assocated with this project at a� ce"� billed toOAOuwme or mCCurITYmOrdinaness as d= nGodes. 51a dards. STATE and I also certify that I have prepared this appl�d0n and that the work to be performed .� be done FEoERAL laws. OATS• � � J3 ApPUCANT SIGNATURE: '�� / OPERATOR /MANAGER � OTHER AUTHORIZED AGENT SY i i t I e PRCPERTY / BUSINESS OWN� ER �q� risnd rM B�'+�P'Rn p-001 of authO�adon to sign is "k*d AUTHORIZATION TO RELEASE INFORh1ATI0N: When aDp liable. I. d owner A operator o1 the property located at the above site address, hereby authorize the release of any and all results. geotechnical data and/or enwrnnmentaUsite assessment info malion to ne SAN JOAcuw CcuNn PuBUC HEALTH SERVICES �NYIftCNMENTAI HEALTH ONISiON as S00 as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: n �f f INSPECTOR'S SIGNATURE: APPROVED BY: ASSIGNED TO: (: Z'1 i Date Service Completed (If already completed): =ee amount: L Payment Type I Invoice I CONTRACTOR'S SIGNATURE: ESIPLOYE:9: //� DATE: Cs EMPLOYEE R: DATE: SEWCE CCCE: /fes Amount Paid �j 37 `Payment Oate Check Received By:�-,,