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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Utility Company <br /> OWNER OPERATOR SLUNG PARTY❑ <br /> Pacific Bell <br /> FACILITY NAME <br /> S(TEADORESS <br /> East 12th Stre ,. ,y" sua.: <br /> Mailing Address (if Different from Site Address) <br /> CrrY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (877)823-9833 233-369-22 <br /> PHONE#2 ezr. SOS DISTRICT - LwATaa CodE, <br /> - •• - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQuESTOR SLUNG PARTY❑ <br /> Scott Tannehill <br /> BUSINESS NAME -- -- PHONE# �T <br /> MALlNG AaoREss FAx# <br /> CrrY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all sde and/or prcjeCt spednc <br /> Pusuc HEALTH SERVICES ENv RCtmENTAL HEALTH DtwS)CN hourly charges associated with this projector activity will be billed to me or my business as identified on this fomL <br /> I also certify that I have prepared this application and that the work to be performed will be done in a0=dance with all SAH JOAQUIN COUNTY Oemence Codes,Standards,SPATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE DATE' <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER Aump-ZED AGENT ❑A_rjP n t- f n r P a c i f i c BP-1 <br /> 1 <br /> YAPFLCAwrandthe prod dxrdart=dontosign ismquinW nue <br /> AUTHORIZATION TO RELEASE INFORMATION:When appficabie,G the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data ark9or emrironrnentaYsitee assessment information to the SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES&wommeilr L HEALTH ONLIMN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: — - <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED By: EyPLCYr°$: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERvlcz COOS: P 1'E- <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice 9 Check# Received By: <br />