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�. SERVICE REQUEST ,r <br /> Type of Business Property FACILITY ID 1r SERVICE REQUEST K <br /> t �� •tT , r�� ��y C.�>c -7/7 s�o�� g(-o�s <br /> OWYNi_RI OPERATOR BtL11NG PARTY C] <br /> FACwy WE r <br /> �,(4A 41—Dl <br /> SrrE ADOREss l L1 <br /> hiu,».r Wxm, darn. / Tf9. sort..Y <br /> Malting Address (If Oifferent from Site Address) <br /> Cm STATE ZIP <br /> 1 , <br /> PHONE#'l AP N# LAND VsE APPucAT)a m 9 <br /> c1r o — // L <br /> PHONE n BOS DMTil1CTt.ACATON CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuLzoR BU-WG PARTY a <br /> BuswEss NAaE , PHOKU Exr. <br /> MAruNGAaDRES3 300 �� Cil r�Jovl� , rC FAX a lP 1' <br /> Crry U L STATE Z1P Cid 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, ackrrowicdga that all site andlor project speck <br /> PUBUG HEALTH SERvtcEs ENvat HTALHEALTH OrvisrA hourty charges associated wish the projecteracgrity wit be baed to me or my business as identified on thG form <br /> I aS3o cur*that I have prepared th. appkzbon and that the work to be performed wit "done in a=daru,e wish all SArt JOAQUiN Co zm Gnimianc�e Codes.Standards,STATE and <br /> FEDERAL taws. <br /> APPLIcmiSKnATurr BATE:_ / _[_ _ �✓�+ � <br /> PRQPERrYI BUW4E.,s OWNER Q OPS;ATORI AAANAot.R OTHER AUTHOP EDACENT <br /> YAPn-r—wisrx( prwo(woortlrrOWfosiprrbr.9, —rill. <br /> AUTHORIZATION TO RELEASE INFORMATION:When apph=blo.L the owner or aperatorof the prop"located at the above sits addra-u.hereby aultto&m ttm roleth_w of <br /> any and all resuU geotechnical data arWor errvi Dn me=V7Y to asu=ment infOrmadon ID ft Sm Jo&c uH COuNTY PuaLic HEATH SERvtcEs ENvhRohma4TAL HEALTH QMS*N a3 soon <br /> as it Ls avadabto and at the same t 3m it is provided to ma or Try representative. <br /> TyPEOF SERY)CE REQUESTED: /-= l 7u h�� r ,� G' .f 4,e-o ft4 &,.),or <br /> Caaat,tFxrs: <br /> INSPECTQR'SSIGNATURE: CONTRACTOR'S SIGNATURE-, / �7 <br /> APPROVED 131: C F�4PL�Yw�: f DATE: <br /> ASSIGNED TO: E1IPLOYEE# �J DATE: <br /> Date ServiCe Completed (if already completed): SERvr M Cool: 'P I L- <br /> Fee Amount: Amount Paid .� <br /> ��7.c�� Payment Date <br /> Payment Type iTlY01t:C# Check# /a 1 (P q p Received By: -� <br />