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SERVICE REQUEST <br /> { Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Srb -70 <br /> OWNER OPERATOR <br /> BILLING PARTY D <br /> FACILITY NAME <br /> — SWESS <br /> ` S' Ko5rE12 R2.60,nd. S a K05TE� <br /> Typo Sudaa <br /> Mailing Address (If Different from Site Address) <br /> CITYn yl ICATL.l <br /> STATE ZIP �y <br /> PHONE#1 Exr. APN# LARD USE APPLICATION# <br /> ( ) <br /> .PHONE#2 raT. BOS�DaTIUCr - LOCATION CODE - <br /> / ^ CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR ��� Kms ' _ BILLING PARTY <br /> IBUSINESS NAMj � 6 <br /> PHONE#q4g Earth <br /> _ MAILING ADORES I5 WAA` 6-rFAR# i'�V <br /> aAy <br /> \ CITY Cj"r G T `Vj STATE /vl LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that an site and/or pmjed specific <br /> PUBLIC HEALTH SERVICEs ENvIRONMENTAL HEALTH DrvlsioN houdy charges assoclaled with this projedor activitywill be billed to me or my business as identified on this form. <br /> I also cerUty that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAORN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: / �_��/®/ /� DATE: 7 mob/(/tJ <br /> � f f <br /> PROPERTY/BUSINESS OWNER D OPERATOR/MANAGER ❑ OTHER AUTHOFJZED AGENT ❑ <br /> I(APq risnct Ut tium Putry proof of aothorizadon to sign is r q.kvd Titto <br /> AUTHORIZATION TO RELEASE INF ATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data an vironmCntallsite assessment Information to the SAN JOAWw COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONIsION as soon <br /> as it is available and at the same Eme it ro i ed to me or my representative. <br /> TYPE OF SERAcE RE II <br /> Y <br /> COlAMEHTS* <br /> ENT <br /> RECEIVED <br /> ��oJU L 2 8 2000 <br /> Y�3, PUBLI <br /> C <br /> HEOALTH 5 RVICES <br /> /�rL ENNPONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNANRE: ONTRACTOR'S SIGNATURE: 6 9� <br /> APPROVED DY:' EMPLOYEE#: ^ 0W` DATE: <br /> ASSIGNED TO] EMPLOYEE#: n DATE: <br /> Date <br /> >Date Service Completed (if already completed): - , . IIIJJJ t SERVICE CODE: <br /> Fee Amount: � � <br /> Amount Paid 3 c70 Payment Date <br /> Payment Type <br /> L Invoice 9' Check# <br /> ,; / / 1 �L Received By: / <br />