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SERVICE REQUEST <br /> Type-of Business or Property FACILITY 1D# SERE REQUEST# <br /> f� u D �' -P FR <br /> C7 0408 <br /> OWNER I.OPERATOR�_ I BI NG PARTY L� <br /> V-f l OLi <br /> FACtuTY NAME + - <br /> a- 1 . -5'w e ,v j.G-P- <br /> SITE ADDRESS 111$ rSW SQA." <br /> Mailing Address (if Different from Site Address) <br /> Ctrl CR STATE Yip <br /> PHONE#i ' �T APN# LANO USEAP.PLlcATmm#. <br /> 00) <br /> BOS bMTRJCT <br /> .: <br /> PHONE#2 -: .. . LocnTTaN CaaE -. <br /> _ CONTRACTOR I SERVICE RE(JUESTOR <br /> REQUESTOR 't�'>� _ )4 1 rj?-j � C/ <br /> wvwv iLIcWGPARTY <br /> -61 AIA V E. A J�- A <br /> PHONE# p EXT. <br /> BUSINESS NME V 0. ` S u✓ �' S �Y`1!! Y CG F! <br /> FAX# <br /> I4lWt1ItG ADDRESS ,�. t2 0 ?C (5-0I C� _ If <br /> cJ STATE LP <br /> Crrr <br /> NG ACKNOWLEDGEMENT: L the undefsigned Property or business owner,operator or authorized agent of same,acknowledge that all site and/or project sFedFC 4 <br /> BILL! es assocated vritir this projector activity wig be billed tome or my business as identified on this form. <br /> PusuC HEALTH SERVICES EmmcNmEWAL HEALTH ONIStou hourly tharg , <br /> I atso cerdly that I have prepared ttgis p and th the rk to performed w�be done in ac�ardance with all SAN JOnOtm+COviHTY.Or+imanoe Codes Standards,SATE and <br /> FEDERAL laws. <br /> Dare <br /> APPUCWr SIGNATURE: <br /> QHER AUTHORIZED AGENT 0 <br /> PROPENrr!Buslt�Es5 O i°RIAG aTitre <br /> if AaQi r~wris not the 9rl r+C Purry p wf al audwimdam to sign is mWi d <br /> AUTHORIZATION TO RELEASE INFORMATION:When appticabEe,1,the owner or operator ofthe property boated at the above site address,hereby authorize the release of <br /> any and all results.geotechnicat data and/or envimnmentaYsite assessment information to the SAN JOAoti>rt CaUNtY PLMJC HEALTH SeTvicEs E1�IIROf&M AL HEALTH t7rrt5toN as soon <br /> as it is available and at the same t 1111 is provided tome army representative. <br /> TYPE OF SERviGE RECIUESIED: J k4 C D N 5 /V's <br /> COMHIE?PrS: � <br /> PAYMENT <br /> -RECEVED <br /> ►SAN . 203 <br /> i <br /> SAN lol al3lN COUNTY <br /> pil9LIC HEALTH SFRUICES <br /> .i ENVkRONf�iFNTA.'�wcF.l,lH piV1510N <br /> INSPECTOR'S SIGNATURE: - CDtiIRACroR�s SIGNATURE <br /> 1:StPtCTEEt -22 110 <br /> DATE-'APPROVED Sr. <br /> E>vPLOYeE#: DATE: <br /> AssIGNED <br /> rvice Cam Ieted (if already completed}:' S Caoar ... P l.E: <br /> Date Se p <br /> Fee Amon <br /> Amount PaidPayment DateInvoice# — Chedt#. eceiv 13y:Payment Type . ro <br /> n <br />