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17-1999 9:40At4 FRUt 1 <br /> P. I U <br /> s SERVICE REQUEST v <br /> — <br /> Type of Business or Property 1 FACILITY ID SERVICE REQUEST$ <br /> SC <br /> a-\ b V- *-- 11� 4(0-1 O n'• <br /> OWNER I OPERATOR BILLING PARTY Q <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 3rr�.r Numev OhCt10n �` 1 �� <br /> SV•NN.m• TWO, <br /> Mailing Address (It Different from Site Address) <br /> "-->-0 C> 1 s <br /> CITY ` <br /> STATE <br /> PHONE#1 APN 9 LAND USE APPLICATION� <br /> 0 61 <br /> PHONE#2 W. BOS DISTRICT <br /> l.r?r;AT10N Goo@ <br /> CONTRACTOR I SERVICe,REOUESTOR <br /> REOUFSTOR r— BILLING PARTY 11 <br /> ..� , tt 4Ctq <br /> BUSINESS -- <br /> NAME PHONE# Ext_ �$ <br /> SCO Co • (!gig. <br /> MAILING AOQaccg l l� `\ �C FAX# '?q, "�- _ -;k-� <br /> Crrr ry STATE �� — <br /> BILLINQ ACKNOWLEDGEMENT, I. the undersigned properly or business owner, operator or authorized agent of same. 00ma,le190 that aA side andtor proiect specfic <br /> PUBLIC HEALTH S5$voc S ENvrRONuENTAL HEiALTH ONISION hotxly Charges associated with this projed ar acilvity will be blued to moor my business as Idenafled on this IOrm. <br /> I also certify that I h repared lh do the work to be perform be done in accordance with ad SAN JOAouw COuNrY Ordinance Codes.Slandmdr,STArE and <br /> FEDERAL laws, <br /> APPLICANT SIGNATURE: GATE:_ 7 i�`�I q A <br /> PROPERTY IBUSINESSOWNER Q Q+ERATCR/MiwACAR Q CTHERAuMCRIzEOAGFW ]JYt]1 CC- <br /> It APKC wt is nal die QS4W P5M yad of wrlAo hitlon to sign is nqu&vd <br /> AUTHORIZATION TO RELEASt INFORMATION:When applicable.1.the owner or operator of the property Iomwd at the above Bite address,hereby authorize the release of <br /> any and ad results.geolechnical data andfor emrironrnentaftte assessment Information to Ura Sm JOAOuw COUNTY PUEiLIc HEALTH SONICES ENVIRONMENIAL HEALTH ONIS"as soon <br /> as it is available and at the same dme it is provided to me or my representadve. <br /> TYPE OF SERVICE REQUESTED: <br /> r .'C <br /> COMMENTS: <br /> PAymENT <br /> VIECOVED <br /> JR-20M <br /> 0M <br /> SAID JOAQUIN CUUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'3 SIGNATURE: <br /> APPROVEO BY: 'T EMPLOYEE#: DATE: <br /> ASs1Cimw To: �� EMPLOYEE 4: 0 � I OATS <br /> Date Service Completed (if al ady completed): SERVICE CODE: l P I E:,�7�,OK <br /> Fee Amount: 3 Amount PaidPayment Date i <br /> Payment Type Invoice If Check 4 Received By: <br />