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SERVICE REQUEST <br /> Type of Business or Property FACILITY IDM SERVICE REQUEST <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> (� S"K"'rbw 04smon sb,a Ilam. / <br /> Suds5„ .S <br /> Mailing Address (if Different from Site Address) <br /> CITY i � STATE ZIP <br /> n?o <br /> PHONE 91 ExT• APN A LAND USE APPLICATIGN eY <br /> ( <br /> PHONE#2 err. BOS DISTRICT TOc1,noN CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS"E14' <br /> AME n Jct PHONE �. <br /> MAwNG ADDfZE,ssj / � FAx 0 3 <br /> --_-CITY �T`L / /L STATE ZIP �,J OAC / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,Operators or authorized agent of same, advawledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES EmriacNmENTA.HEALTH Or ts"hourty charges associated with flys project or actvdy wig be billed to me or my business as identified on this form. <br /> I also corufy that I have pro is app6ca and that work to be performed wd be done in accordance with allSAN JOAQUV COUNTY Ordinance Codes,Standards STATE and <br /> FEDERAL taws. <br /> C'1"rAPPLICANr SK,NATU DATE <br /> PROPERTY/SUUiESS OWNER Cl OPERAT 1 MANAGER ❑ QTIFA AVrr auzED AGENT ❑ <br /> tfAPmjc"ranotC>r@LfAmYpadofw6xtudonto sip IsnRwd Title <br /> ,AUTHORIZATION TO RELEASE INFORMATION:When applicable,L the owner oroperaturof the property located at the above site address.hereby authorize the rebase of <br /> any and all results,geotechnical data an/or environmentaUsite arsessmcnt information to the SAN JoAam COUNTY PuBL)c HEALTH SERvicEs EwpohmEwAL HEALTH DNwoN as soon <br /> as it is available and at the same tme it is provided to me or my represen atva. <br /> TYPE OF SERVICE REQUESTED: 4r(aAllk tet-A— <br /> COMMENTS: <br /> E-'�-e� St_�S -�'►'� ��� (� �► z���"�C <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. EYPLO t. rt)t- ) DATE: <br /> ASSIGNED TO: � EMPLOYEE;.. �„ G} C' t DATE <br /> Date Service COMP le Cif already completed): SOMMCODE: P 1 EE <br /> Fee Amount: ' 1 L �' <br /> I Amount Paid Payment Date i <br /> Payment Type Invoice 9 Check# Received By: Cj <br />