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SERVICE REQUEST <br /> y` FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property aO q3 7 <br /> U©0 644r <br /> BlLUNG PARTY Lam. <br /> OWNER I OPERATOR <br /> 4+ EC�/G <br /> � dry #A/ <br /> Facttm NAME <br /> '-1 CE C'641 725"01— <br /> StTEADORESS <br /> orI G4�ES G .4W rra• suaaa <br /> !� str,.t xum6r ncrian SttNsmt <br /> Mailing Address (If Different from Site Address) <br /> V , STATE ZIP <br /> - low 'r,4 <br /> PHHONE#1 �. APN# LAND USE APPUCATION <br /> [ # <br /> I�) `7——/y " & LOCATION C013E <br /> PHONE#� aT SOS Dlswia <br /> - 1535 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY 0 <br /> REOIJESTOR ` <br /> 4 '4H6S ✓.��A/! �+�5 �/J�/�n,N`iJF�,t//'�L .�`/�G� �fC'✓i9CiJ� <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> /�i9G--/�/'L G�/�S �41✓O <br /> FAX <br /> MAI NG AOURESS J ' 7 <br /> P,c)• Be X' 9 3 v <br /> STATE 7JP <br /> CrrY [�TT✓A� � � <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andfor project spec.c <br /> PUBLIC HEALTH SERVICES E-mRCN"AL HEALTH cimsi0N hourly charges associated wit this project or activity wilt be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appficatien and that the work Z be performed will be done in amontanoe with all SAN JCA"CODUNNIY Ord(ansa Codes,Standards,STATE and <br /> 'FEDERAL%WS. BATE: e961--)'110-3 A,PPUCANTSir.NATURE:_<: <br /> _ - - <br /> APPUCAHTSIGNATURE: ;gyp <br /> PROPERrYISUSWESSOVYNER Q OPEeRATOR/VMAGER � OTHER AUTHORIZED AGENT <br /> If Aav[X.wr is nQ(ta urr'i pmol of autlronadan to sign is rtgvkW Ti ti s <br /> AUTHORIZATION TO RELEASE INFORMAT[ON:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data ancVor ermroamentallsite assessment information to the SAN JOAOUW COUNTY PUSUC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION as soon <br /> as it is available and at the same lime it is provided to me or my represenratN*. <br /> TYPE OF S RVICE•REOUESTED: QYE�Flu /G <br /> ?2�r✓,�rw/T�a C)rC' <br /> . c%s. r P�r��N� . <br /> --EG}=kV <br /> COMMENTS: <br /> �ON262�OJ <br /> PUNII�JALTK SERVI"LSc <br /> tJVIRO�t,4C"J�+!' Ot A�JH 01V'titON <br /> INSPECTOR'S SIGMA E: CONTRACTORS SIGNATURE: f <br /> APPROVED BY: jr' EmPI.Ma#: C r3A7r—' <br /> ASSIGNED T0: z <br /> EMPLOYEE#: —F7 �' J DATE: <br /> Date Service Comp) ed galmady'completed): SERvICECODE f PIE: (y <br /> Fee Amount Amount Paid ::2 lip7 <br /> Payment Date <br /> Payment Type Ll/ <br /> Invoice# Check# , Receiv By: <br />