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-1 7-1 x_1941 9:40AH FFUP:1 P. '1 0 <br /> SERVICC 111701,1EST 16 J/ 3 9 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r <br /> OVO4;k J OPERATOR BILLING PARTY I] <br /> IN <br /> FACILrTY NAME <br /> STTE ADDRESS <br /> Sheer Number 1. 51f.k Hams Typ6 SuNrY <br /> Mailing Address (if Different from Site Address) <br /> CITY 7/ ` C'� STATE ZIP <br /> PHONE#1 p im APN# LNo UsE APPLICATION# <br /> (Cal LA, to <br /> PHDNE 42 Exr. BOS DISTRICT l.r?r AT10N CQo <br /> CONTRACTOR.I SERVICE:REQUESTOR <br /> RF:GUESTOR <br /> BILLING PARTY(Z <br /> auslrrEss NAME P1N]NE# O S- ^ 1� EAi` O <br /> S <br /> Cm STATE zip <br /> BILL.N_Q ACKNOWLED MENT, 1, Cha undersigned property or business owner, operator or authorized agent at same. acknowledge that all site andlor project 5peuric <br /> PUSLIC HEATH SERVICES I NUENTAL HEALTH DN7sviN hourty charges associated with this project ar activity witl be)glad to moor my business as identified on this form, <br /> I also certify that I have p par this a mWn and Ie work to be performed will be done In,rocordanco with all SAN JOApuIN CouNtY Ordina a Codes,STsndards„Si AYE and <br /> FEoERAL laws. <br /> APPLICANT SIGNATURE: DATE: I 7"1-1,.C%�, -. <br /> PROPERTY/BUS1NESS ER C] CERATORlMtANArilz C7 OT1iERAUrHQRIZEOAGENT <br /> Arrrrca r i3 na d e�Prnvf n1 auln4o*800n ro alga is rhrqu6sd <br /> T!r r n <br /> AUTHORIZATION TO RkLEASE INFORMATI N:When apOcabk:.I,the owner or operator of the property kx:5W at the above lite address.hereby authorize the rPiea5e of <br /> any and ail results.geotechnical data andlor emironmentaft(O assessment Information to the SAN JOAOM COUNTY F'UHLIC HEALtw SERviCES EKvrRQNMWAL HEALTH Oml."as soon <br /> as it is available and at lie.same Ime i(*provided to me or my re?resentaUve. <br /> TYPE OF SERVICE REQUESTED' <br />� CoMME:NTS; <br /> INSPECTORS SIGNATURE, CONTRACTOW3 SIGNATURE, <br /> A ; ,:-,. <br /> PPNQVSo¢Y' EMPLOYEE#: DA <br /> ASSIGNED TO: EbMPLOYEE M DATE <br /> t� Date Servica Completed (if already Completed): SERVICE CODE: P I E. <br /> Fee Amount: Amount Paid Payment Date <br /> Payma:Tt Type <br /> invoice# Check# Received By: <br />