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i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UrFSJ k - <br /> I <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILrIY NAME <br /> $RE A.DORESS 4�35�, - q– ) ✓� <br /> Nwbr WDctbn (,L/—� /�wi't7 <br /> W SUaDD <br /> Mailing Address ilf Oifferen from Site ddre <br /> CITY STATE ZIP <br /> HONE#�� �3O APA# LANDusEAPR D# <br /> �Y) S <br /> PHONE#2 EYc BOS DISTRICT ,.� LOCATIONCODE: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Bu-uw PARTY❑ <br /> BUSINESS NAMEPHONE# <br /> l/lit v G{ e LLC{ L v �S L i <br /> MAILING ADDRESS _ - FAX <br /> CITY C STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same• acknowledge that all site and/or project specific <br /> PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH 0AISION hourly charges associated with this projector actvty will be billed tome army business as identified on this fomT. <br /> I also mnily that I have prepared this app lim' and that the work to be pedomhed will be done in accordance with at SAH JOACUIN CouNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPuG1NT S,GNATum v --- DATE: v <br /> PROPER IBUSWESS OWN OPERATOR I MANAGER ❑ OTHERAUTHORREDAGENT ❑ - �- <br /> YAaa.Gwrcxl lM BrtrcPAmr prudofaufhartradon to sign u requbDd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property kxaled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or emvimnmentallsite assessment infannatlon m ft SAN JOAOUw CoLiNTY Pusuc HEALTH SERvhcEs ENVRONMENTAL HEALTH OIVIsioN as soon <br /> as it is available and at the same time it R provided to me or my representative; <br /> TYPE OF SERVICE REQUESTED: ' <br /> COMMENTS: <br /> W�A � <br /> INSPECTOR'S SIGNATURE: • CONTRACTOR'S SIGNATURE: <br /> 'APPROVED 8Y: EMd <br /> PLOYEE#: DATE: Z <br /> AsslGNEOTO:- / IG EMPLOYEE t. DATE: v <br /> Date Service Completed ('tf dy completed): P fE <br /> Fee Amount: 7P-2—' . Amount Paid Payment Date <br /> Payment Type Invoice Check# Received By: <br />