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0 SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST <br />BILLING PARTY ❑ <br />OWNER I OPERATOR <br />FACILITY NAME <br />SITE ADORES$ <br />Strut`Imt Ty" Suit2 <br />Strut 1UMON 01111 01 <br />Mailing Address (if Different from Site Address) <br />STATE ZIP <br />CITY <br />T• APN # LAND USE APPUCATiON # <br />PHONE #1 <br />( <br />EXr• BOS DISTRICT LOCATION CODE .: <br />PHONE #2 <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />BUSINESS NmE <br />MAILING ADDRESS <br />BILLING PARTY ❑ <br />PHONE # W. <br />FAx# <br />STATE ZIP <br />CITY <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated wiM this projector activity will be b filled 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 wm be done In ac=dance with all SAN JCAGUIN COUNTY Ordinance Codes, Standards. STATE and <br />FEDERAL laws. <br />DATE• <br />APPLICANT 5IGNATURE' <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />NAPRjCW is not the 81 LW Pura prod of audio h360n to sign is rp jkW Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I. 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 arnUor environmentallsite assessment information to the SAN JOACUN COUNTY Pueuc HEALTH SERvhCcS ENVIRONMENTAL HEALTH OMSION as soon <br />