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SERVICE REQUEST <br /> 1 <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> BILLING PARTY <br /> OWNER/OPERATOR <br /> I I <br /> IFACILITY NAME <br /> SITE ADDRESS <br /> Strep Humber Okecdon <br /> SiltK Name type S.ela d <br /> Mailing Address (if Different from Site Address) <br /> STATE 7jP <br /> CrrY <br /> PHO.HE#1 =APN LAID USE APPLICATION# <br /> ( } <br /> Bos DISTRICT LDCAr1oN CODE <br /> PHONE#2 ' <br /> CONTRACTOR t SERVICE REQUESTOR <br /> BILLING PARTY 0 <br /> REQUESTOR <br /> PHONE# <br /> BUsINEsS NAME <br /> FAx# 4 <br /> MAILING ADDRESS <br /> STATE ZIPCay <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property Orbusiness owner,operator orauthori mM agent of�me e.or m business <br /> that ad site and/or proiect specific <br /> pmjW or activity bilied as�� on this form. <br /> ?-jsuc.4FALTH SERVICES EwiRoNmENTAL HEALTH DIVISION hourly charges with this <br /> I also cer6ty that I have prepared this application and titat the work to be pwftnW will be done in a=Wa=with ail SAN ZAGUIN COUNTY On ence Codes.Standards.STATE and <br /> FEDERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MMAGEER0 DTA AU7mcF4M AGENT 0 iitie <br /> JAPrucaurrsiWftdLL22eMprodof asibaritidon tDst"Is <br /> mitikid <br /> AUTHORIZATION TO RELEASE INFORMATION:When appfkaDK L the owner or operator of Ate INOPOM located at tits above site address.hereby audwriZe the release of <br /> WY and all results.geotechnical data and/or em arimemadsleassessmentob Mellonto die SAN jOAQM COUNTY PUMX HEALTH SERVICES EW ROMMENTAL HEALTH OtvtsloN as soon <br /> as it is available and at the same tkne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED SY: xPLOYE n I DATE: <br /> ASSIGNED TO: ! d�fPLQYE_=R DATE; <br /> SERVICE CODE: I P!E: <br /> Dace Service Completed (If already completed}: J <br /> Fee Amount: � Amount Paid � Payment Oate <br /> Received By: <br /> Pzyment Type Invoice# <br /> Ctleck# ( <br />