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SERVICE REQUEST <br /> SERVICE REQUEST <br /> Type of Business or Property FACILrN ID# <br /> Bawr+c P ❑ <br /> OWNER I OPERATOR <br /> FACILITY NAME �� <br /> SITE ADORus aCj S? <br /> o�CJ' sa,.[nvi,+o.r ar.�ion �*••e�L,�• rF" suA,.A <br /> Mailing Address (If Different from Site Address) <br /> ! STATE zu' <br /> CrTY <br /> PH NE#7 APN# Lmio USEAPrur-Awx# <br /> ( 7; <br /> PHONE#2 *- B05 DwRicT LocAmN CODE- <br /> CONTRACTOR I BERME REQUESTOR <br /> ReauESTOR � _ ^ � ��©�� Bu-Ltr+c PARTY 0 <br /> BUSNESS NAME <br /> MasLintGAaDRFss � fj � FAx# <br /> CITY � � 1�e�l STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the w-Wersigned property or business owner,operator or authoraad agent of sauna, adma* ge that all axle arao(prnlod specific <br /> Pueuc HEALTH SFRvrGEs ErwiRai-+EnTAL HEALTH OrvZ"Warty d2rges associated with Uric protect or acrtY4 wig bo bred to me or my business as identified on d=form <br /> I alga cartiy that I have prepared this appGcalion and Vrat the wom to be perfomrcd wA be done in awardar"wish all SAN JOAafrr CouK Y Ordrrtvrtav Codas,Standards,STATE and <br /> FEDERAL taw.. 4 �7 <br /> APPLrCAKT SKd4ATURE: DATE �{- ✓� © L fy� <br /> PRGPERTYI B.tsrnESS QWNER OPERATOR WW04ER OTHMAuTHORaZEAAc,ExT <br /> XAvpr,cwt is w(Ow BtLerr:PA Tru proal odAWWf icon to 4w jx r qWW r 1!• <br /> tAUTH ORVAT ION TO RELEASE INFO RN16M }N:When appkzbb.L the owner oropexairuof that proparty iocatod at the abore site address.hereby aulmdze the release of <br /> any and all results,geotechnical data aaj, or ormorunenokl5 a asscza mt informaGan to the SAtr JOAourr COulrrY Pumuc HEALTH SERvicES E.NvrRON►ENTAL HEALTH aNWON as soon <br /> as it is ayadabte and at the Same tine it is provided to me or my represenutm <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTs: <br /> INSPECTOR'S SiG"TURFA CONTRAcroies SniiATURE: <br /> APPROVED 8Y: ESIf'LJY`=1t: DATE: <br /> ASSIGNED TO: Ak n" ExnoYEE#. Q DATE: <br /> Date Service Completed (rf already mple ): Sst+rtc>coo C `j P!E: <br /> Fee Amount: -7 Amount Paid Payment Date <br /> Payment Type Invoice# 7ECheck# 7717Re eived By: <br />