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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ly—( [C—[.T -1 1 f � Ir <br /> OWNER 1 OPERATOR�� �� tLLNG PARTY❑ <br /> FACSLm NAME <br /> 5riEAtjD�IREss, f p <br /> Suva Nme 'hc. s„Ete a <br /> Mailing Address (If Differen om Sp Address) <br /> ( v �{ <br /> CITY STAG zip <br /> PHONE#'1 txr. APN# LAND USE APPuwioN# <br /> L4 I <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> `r -Z- <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REDUESTOR + BLUNG PARTY C1 <br /> BUSINESS NAME ��� PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> 9 L�2- (L,q-7 <br /> CITY J�` y� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner,operator or authorized agent of same, acknowledge that ad site and/or project specific <br /> PUBLC HEALTH SERVICES ENmRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as idended on this form. <br /> I also certify that I have prepared thisWappfiqtkonat the wet to be performed will be done in accordance with all SAN JGAOUw COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: �' / DATE: ritJ <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHoRRF_D AGENT 0 <br /> 1f APpUGwT is nor Nie exLm Purr.pm&cf sudxvir;adm to sign is roquM Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the,property Ionated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaltsite assessment information to the SmJoAOuw COUNTY PUBuc HEALTH SERVICES ENVIRONNENTAL HEALTH OMBION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: t�✓� <br /> p e'V.r <br /> r l RON A,? <br /> AC k y� 1c r <br /> CTy blft�f <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: Y V EmPLL`Y--}1 DATE: <br /> ASSIGNED To: EMPLOYEE* �i DATE: <br /> 01 <br /> Date Service Completed ('if alrea completed): SERVICE Coat=: <br /> k <br /> Fee Amount: b Amount Paid L 1 Payment Da J-6 _.4� <br /> Payment Type Invoice# Check# �F�j Received By: <br />