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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#� S, IC <br /> SERVICE REQUEST# <br /> COM I l `i'�� V1 1—I Y5 <br /> OWNER OPERATOR BILLING PARTY�j <br /> FACILITY NAME <br /> SIrEx0FS SS 5 as..rxeeir C.12T IFwp ) ST ref <br /> + <br /> see.e <br /> Mailing Address (If Different from Site Address) <br /> — 238L A FAS N- v C' c <br /> CRY STATE ZIP <br /> J OCP 952., <br /> PHONE 91 ear. APN# LAND USEAPPUCATpN# <br /> R dj) <br /> PHONE#2 BOS DISTRICT LacATpN CooE: <br /> 4Ta Z <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR / - BLLa18 PAR"D <br /> BUSINESS NAMEPHONE# ` V� <br /> e 7 c. 2400 <br /> MAILING ADDRESSn FAX# <br /> r <br /> Cm C „0. 967— <br /> 2 STATE oR Zp 9524) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specfic <br /> PUBLIC HEALTH SERVICES EmimONMENTAL HEALTH DPnsm hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also camly that I have prepared this application and that the work to be performed will be done in accordance wilh all SAN JOAcuw COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALIaws. —//�/_f _ ///J J ',//- <br /> APPLICANT SIGNATURE: /Y, /A . �l nA�N K" DATE: <br /> PROPERTY/BUSINESS OWNER 1 TOR/MANAGER 0 OTHER AUIHOMED AGENT f r/ <br /> ni..I Ci <br /> d APPLcAvr is not de Buss PA ..pmdotwdehadon W Sir is Wdred j rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the ovmer or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnkal data anU/or env ronmentadslte assessment information to the SAN JOAauW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D WION as soon <br /> as 4 is available and at the same trtne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> V <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: �' CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYn-9: DATE: <br /> ASSIGNED To: cL EMPLOYEE#. DATE <br /> Date Service Completed (N already completed): - SERVICE CODE: 17 1 'PIE: Lj <br /> Fee Amount y D O Amount Paid i.f��8r Payment Date <br /> Payment Type L/ Invoice Cheek# (� r3 RsedwdBy: <br />