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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Utility Company <br /> OWNER I OPERATOR SLUNG PARTY❑ <br /> Pacific Bell <br /> FACILITY NAME <br /> SITE ADDRESS <br /> East 12th Streg,, H,,,„ <br /> 11Q.T ,y„ <br /> Mailing Address (if Different from Site Address) <br /> 2600 Ca n. Rooril 3EOO K-- <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (877) 823-9833 233-369-22 <br /> PNONEIIL err. SOSDm7Fj= = LOCATbNCOO E" <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RFQUESTOR BLUNG PARTY Q <br /> Scott Tannehill <br /> BUSINESS NAME - -- PHONE torr <br /> MAI ING ADOREss FAX# <br /> 1 113 North McEiQwe. 111 t-va rd STATE ZIPCITY . <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acimcwtedge that ad sr'te andfor project specific <br /> Pusuc HEALTH SERvcEs EwRcNk;EmTAL HEALTH OmsmN hourly charges associated with this projed or acth*will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed wig be done in—rdance with all SAN JOAQUIN CouNTy Ordinance Codes.Standards.STATE and <br /> FEoERAL laws. <br /> APPLICANT SIGNATURE: J DATE: ` 1 r <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER OTHER AUrrio ED AGSM O B.C�P ri f f a r Par-i f i r- Be l 1 <br /> IrAPP.Cwris rzt tde rwn proof d aadrorhadon to sign Er nqukw rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t 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 aniUor environmentallsit7e assessment information to the SAN jMQUIN CQUHrr PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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. CONTRA=R'S SIGNATURE: <br /> APPROVED BY: EStF'L»^Yrs: LATE: <br /> ASSIGNED TO: Et+PLOYEE DATE: <br /> Date Service Completed (cif already completed): SamCECOOE: P 1'E:. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Checlt# Received By: <br />