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.. SERVICE REQUEST ~ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST ft <br /> J �, , %. l� IC / 6U � � 71 v�, 2� 7CJ <br /> OWNER I'OPERATOR BILLING PARTY 0 <br /> FACILITY NAME } f <br /> J.` i rrr c.Z 5'4'1' <br /> SITE ADDRESS � <br /> � /"'/J f <br /> 4-o—t,y /G-/StragI Xumbx Olrecaan �/ �.'+`fes 16 sVed HIM* T <br /> Y� Sully r <br /> Mailing Address ( Different from Site Address) <br /> CITY STATE ZIP' <br /> 14'r= <br /> �. <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#z EXT. BOS,DIsTrtscT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY Cj• <br /> BusiHzss 11AME / ✓ PHONE-# EAT. <br /> MAILING ADDRESS <br /> �7 FnxO <br /> Ctrl r/� STATE zip L 0 <br /> BILLING ACKNO%WLCDGEMENT: I, the underAnod property or business owner,operator or authorized agent of same, acknowfcdge Ula(all site andlor project Specific <br /> PUDLIC HEALTH SERVICLS EWRONIAENTAL HEALTH Omsion hourly chargr'astodated with this project or activity will be billed to me or my business as identified on thl;form. <br /> I also certify that I have preparMLhisam' andhat wor performed will bedone in accordance with all SAN JOAOtPN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL/awls, I6" <br /> APPLICANr SIGNATURE: <br /> DATE' <br /> PROPERTY I BUSINESS OWNER O OPERATOR/(b1A14AGER ❑ OnIERAumortizco AGENT <br /> If Amiz-wr is nit tho Doric Pura Pmol of surho.*ation to sign is roquGvd <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,010 owner or operator of the property located at the above site address,hereby autlTorize!hc release of <br /> any and all results,geolechnical data and/or environmental/s4a assessment information 1e the SAYt JOAOUIN COUNTY PUst.1c HEALDI SER\ocrS ErrMONmCNTAL HEALTH Dm:,ION as soon <br /> as it is available and at the same time itis provided to me or my represeatative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RAYMEfV <br /> RECEfvF-l <br /> FEB 'm- <br /> SAN JOAN, <br /> PU$LIC HE,',,. <br /> A ' <br /> ENVI€I'ChlF.4,�rr�' <br /> INSPECTORS SIGNATUR CONTRACTORS SICNAT1JRE: <br /> APPROVED pY:. EMPLOYEE#: <br /> DATE: <br /> ASSIGNEDTO: EMPLOYEE 2 L� <br /> DnTt <br /> J <br /> Date Service Completed {if already camplet d}: SERwCECaDE: <br /> PlE: 23 d <br /> Fee Amount <br /> Z6 7 Amount Paid Payment Date <br /> f I� <br /> Payment Type Invoice IV ChCCk# <br /> 12-4(o'70 Received By:��� <br />