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SERVECE REQUEST <br /> �rype of Business or Property FACILITY ID ar SERVICE REQUEST» <br /> OWNER I OPERATOR BILLING PARTY <br /> FAciuTYNAME, _ r <br /> SITE ADDRESS i <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 W. APN# LAND UsE APPucAnoN W <br /> PHONE V UT. BOS DISTRICT Lowiom CODE. <br /> CONTRALTO SERVICE REQUESTOR <br /> RLQUESTOR Bu t NG PARTY❑ <br /> BusmFss NAME PHONE# Eu <br /> MAILING APORES3 FAX 9 <br /> CITY STATE Clrl <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the and ed property or business owner,operator or authorized agent of same, adaiowfedgo that all site and/or project specific <br /> Pusuc HEALTH SERVICEs ENmCNr&aAL HEALTH hourly charges associated with this pro)ect or activity will be tried tD me or my business as identified on this tont <br /> I also certify that I have pared be performed • done in aomalance with aA SAN JOAOM CouNtY Onfinarroo Codes,Sfandards,STATE and <br /> FEDERAL laws. A A <br /> �j <br /> APPL icAsT SIGNATUREVKA1 DATE: Z r < 02—C <br /> PROPERTY!BUSP SS OWNER ❑ 'CPETiATOR I"AGER- ❑ OT"AUDiORLZED AGENT ❑ <br /> itAA-Liv isno(fir.B(L[r�PAmYprodcewdwrizatlonbsign isnpuird Till* <br /> AUTHORIZATION TO RELEASE INFORMATION:When appbcable.L the owner or operator of to property located at the above silo address,hereby authoitze the rebase of <br /> any and all results,geatedMical data ar0or errA rutlenW3b atsuawnent inform4o i to the Sm JoAam COWY Puom HEALTH SERvICEs ENviRomANTAL HEALTH DmsioN as soon <br /> as it is available and at the same time A is provided to me or my mpreuntallm <br /> TYPE OF SERME REQUESTED: <br /> COMMUM: <br /> RECEIVES <br /> APR 9 2002 <br /> SAN JOAQUAri CnUNIY <br /> PUBLIC HEALTH SERVICC:: <br /> ENVIRONMENTAL HEAL]H DIVI <br /> INSPECTOR'S SIGNATU E: CONTRACTOR'S SIGNATURE: <br /> APPROYED BY: ,A, j) ESIPLOY:.z 31: DATE: — r{ <br /> ASSiGNm TO: st,rJ EwPtaTEEtI: � DATE: <br /> Date Service Completed [rf already completed): SE mmcooe �� -P I'F—,—z3©s�- <br /> Fee Amount: �eQ Amount Paid t Payment Date <br /> Payment?ypeInvoice# Check5 Received By: <br /> s <br />