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SERVICE REOUE5T <br /> Flo <br /> iness of Property FACILITY 10 a SERVICE REQUEST / <br /> BILLIIIG PARTYTOR <br /> FACILfrY N V —DE�PQ <br /> SITE ADDRESS }}-- <br /> C�-�(G N G/� "'�`Str� H .. 04ecoon S"*I N�m� iron Swig/ <br /> Mailing Add r ss (If Different from S c d1 l^ <br /> DC7 -i--: --DI V I 147 <br /> Z 4 r(, l�& �� L'v� -7> <br /> ' E <br /> � b L <br /> CfTY �1�i� STA[ ,� ZIP <br /> PHONE X1 <br /> � <br /> 1 I C� �T APN9 WOO USE APPLICATgN C l� <br /> PHONE f:2 <br /> SOS DISTRICT LOCATIoa CODE <br /> , <br /> ( <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQIIF.STOR BILLING PARTY❑ <br /> BUSINESS E Jr� �I.C _ ----- PfIQ6 N 2- <br /> MAILJIG4DDRESS n ��\,� S ( E . 1 DDD F-" �E Z-( �01 <br /> NITACTrY ! /C�l V 1J STATE(7 LP <br /> BILLING AC�KNO�W—L�EDGEMENT: I, rhe undersigned property or business o►vner, operator or authorized agent of same, adurowledge that ad site and/or project specific <br /> PUBLIC HEALTH SERVICES Et+VIRONMENTAL HEALTH DrvisioN hourly charges assocated with this project or activity will be Wed to me or my business as Identified on this form. <br /> I also certify that I have prepared this application and that the work I,will be done in accordance with aM SAN JOAOuW COUNTY Ordinance Coles.Standards,STATE dnd <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER In OTHER AUTHORIZED AGENT ❑ <br /> if APPLoc r r a not Ur 8B r�prod of authomadan to SJpn is requirW 1 i f I e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.the owner or operator of the property located al the above site add(ess,hereby authorize the release of <br /> any and all results,geotechnical data and/or envlronmenlaVsile assessment into n1adon to the SAt1 JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at Uie same dine it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: C� <br /> �;(, �f7/Nb "7L �t SclsS QI�GLr�v6 �a 10-9672,,,U 4T <br /> PAYMENT <br /> JW2 89 <br /> SAN,JCJAOUIry COUN-rt <br /> PUBLIC�-E•iLTH SERVICE; <br /> ENVIE"WENTAL HEALTH ON191G,• <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE 9: DATE: <br /> ASSIGNED T0: <br /> EMPLOYEEh: O P DATE: 4 <br /> Date Service Completed4f already completed): SERVICE CODE: V� I P I E: <br /> Fee Amount: Amount Paid Payment Qate !+11P <br /> eceived By: <br /> Payment Type ✓ Invoice fi Check 4 R <br />