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.';,.'.+CJ-�•.I/F�t:.;F. I'I, :-'V. laKlS^n i'!R.'1X°!t� Tq�.� �' ' <br /> r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR BILLWG PARTY Ll <br /> UA\AK ti <br /> FA.ctuTY NAME <br /> SITE A000pEss <br /> U So.Nrrrrbr <br /> �'P� Suits id <br /> Mailing Address (If Different from Site Address) <br /> Gm �• ;} STATE �� z'p <br /> PHONE#i �V *• <br /> N# LANo USE APPUCATION# <br /> PHONE#2Q r q ]� ter. BOS DiSTRtGT LocATlotr CouE <br /> i o', 1 U CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Baf.LIHG Pty,o <br /> wj w cry <br /> BUSNESS NAGE <br /> 1�1 �V� PI�axE# axr <br /> MAILING ADDRESS FAX <br /> t$L 1 <br /> CITY STATE t ZIP ' <br /> BILLING ACKNOWLEDGEMENT; 1,the undersigned properly or business owner,operator or authorized agent of same, admowledrjn ifiat al site uNor pm*1 specific <br /> PusLc HEALTH SERv>GEs EwRa%a&wAL HEALTH Ofm*N hourly charges associated with tuts project or adtvtly will be btiled to me or my business as idix tied on this form. <br /> I also certify that I have prepared this appf ati n and tttxt the work to be perforated wil be done in ac==ne wilb all SAN SOAMW CWNTY Onf narx a Codes,StandAMA•ySyk*-i q <br /> FwERAL laws. <br /> APPLICANTSiGNATURE: /� f' DATE: , <br /> PROPEArYIBUSINESS OWNER ❑ OPERATOR MANAGER (2 OTHER AUT}I)P=AGENT 0 <br /> !fAPPdZANTitnOtrhe&MP' r.dro aofY&0*8ddatoAttarisr9q.Lkw Till* <br /> AUTHORIZATION TO RELEASE INFORMATION When applicable,I,the owner or operator of the property located at the above stte address,hereby authorize itne release of <br /> any and aJ results,geotechnicat data an LYor amridonmentaUsite assessment information to he Saw JoAouhN CouNTY Ram HEALTH SERvKm ENvtRcm*uTAL HEALTH Oms"as soon <br /> as d is available and at the same time it is provided to me or my representative, <br /> TYPE OF SERVICE REQUESTER: <br /> COYHEwrS_ <br /> I <br /> INSPECTOR'S SIGNATURE: CoNTRACTOR'S SIGNATURE; <br /> APPROVED BY: ESWI.d�YE�fi:. ATE: <br /> AsshGHED TO: EMPLOYEE$: DATE: <br /> Date Service Completed (if already completed): <br /> SERVICECODE P!E: <br /> Fee Amount Amount Paid Payment Data <br /> Payment Type = Invoice# Check# Received By: <br />