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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s � <br /> OWNER I OPERATOR BILLISIG PARTY Q <br /> FACILITY <br /> SITE ADDRESS <br /> �'j)/r1/`1�/�) <br /> ld 1d1 .,,. Otncflon \j I TO fe�— StrMtEOA P <br /> T" SaihA <br /> Maillp.Address (If Different from Site Address) <br /> �• d <br /> Circ _ ®APT i i�j e STATE ZIP <br /> PHONE#1 ar• APN# LAND USE APPUCATiON'# <br /> PHONE#Z BOS D1sr = LOCAmON CODE. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RECUESTOR BILLING PARTY❑ <br /> V <br /> BUSINESS NME PHONE# taxi. <br /> I G671 <br /> MAiUNG5§, �� FAXI# <br /> CITY � � .- STATE CA <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,admowledge that ad site and/or pmol spedfic <br /> Pusuc HMTH SERvICES EtWIRONkeffAL HEALTH 0 charges assoaated with Cris projector activity will be billed tD me or my business as identified on this form. <br /> I also cenify that I have pre this application and the wont to be performed will be done in accordance with ad SAN JOAam COUNTY Ordinww Codes,Standards,STATE and <br /> FEDERAL laws. f <br /> APPLICANT SIGNATURE: (/��(� DATE: <br /> PROPERTY/BUSINESS OPERATOR/MANAGER m»� P OTHER AUTHORIZED AGENT T �.J r,4642-- <br /> IAPRr- risnat proofofauarmf edoetospe;s rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,i,the owner or operator of the property located at the above site address,hereby aur wft the release of <br /> any and ad resub,geotechnical data anUkr amrironmentallsda assessment inkumadon to the SIN JOAQUIN COUNTY PUSUC HE&TH SERVICES ENVIROGIENTAL HEALTH DIVISION as soon <br /> as d is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: U L p r2e126, �_U tg> �b W w ,K R ` oV L, <br /> COMMENTS: 1 V `� �(�U r" K,v ("'li'"1 <br /> INSPECTOR'S SIGNATURE CL-1 CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: Or d Eumvr--tl: ATE: <br /> ASSIGNED T0: EMPLOYEE*: DATE: <br /> Date Service Completed (if already completed): V SERVICE CODE: .0 -P I E:. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Checit# Removed BY: <br />