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11%.W .i <br />SERVICE REQUEST � <br />Type of Business or Property <br />CONTRACTOR/ <br />M geAj <br />FACILITY IDK <br />PIpNE fi [sz <br />SERVICE REQUEST <br />.r <br />MALLmG ADDRESS <br />FAX# <br />'e,3z— <br />F/ (0 <br />_ <br />CITY 1 r A STATE ZIP p�-3 <br />OWNER OPERATOR <br />BUING PARTY [I <br />�>4.5 <br />FACILITY NmE <br />oe LJ"s� <br />INSPECTOR'S SIGNATURE: <br />SITE ADORES$ �t <br />COMMACTOies SIGRATURE. <br />APPROYEDBY: //./// <br />- <br />`7 se.�x�.ro.r <br />a4.co� <br />mrn,m.. <br />DATE: <br />14 <br />TYP. <br />sun. r <br />Mailing Address (If Different from Site Addressl <br />EMPLOYEE Q�r>a <br />3zS D <br />. Date Service Completed (if already completed): <br />CITY <br />.P f -E y <br />2 3,0 <br />STATEp <br />- ]gy <br />19- <br />c�Q <br />J <br />Amount Paid <br />PHONE 91 Uray. <br />APNA <br />LAN" U5E APPUCAT)oNa <br />PHOME #2 aT• <br />BOS DISTRICT <br />LOCATION CODE- <br />ODE <br />CONTRACTOR/ <br />REOUFSTOR i BU -M PM <br />�Nyi <br />M geAj <br />BUSINESS NAPE /r <br />JT <br />PIpNE fi [sz <br />33—O�ti B <br />MALLmG ADDRESS <br />FAX# <br />'e,3z— <br />�l75 L <br />_ <br />CITY 1 r A STATE ZIP p�-3 <br />BILLING ACKNOWLEDGET,IENT: I, the undersigned property or business owner, operator or authorized agent of same, acJaoWedge Gut ad sile and/or project specific <br />PUBLIC HEALTH SERVICES ENVe Gt4WENTAL HEALTH DIVISION I)GUOY charges a55"dabM wdh Geis pmjector acS wit be bi➢ed b ma or my business as identified on dtc tuna <br />1 also tartly that I love prepared Ina appfrabon and <br />FEDERAL laws. �i l <br />APPLKAxT SiGmTURE:•__.z <br />PROPERTY I BUSINESS OWNER <br />pert meed wd be dont n a=dar" with all SW J"Aam CouNly Ordinance Codas. Standards, STATE and <br />DATE: YLl2/ /61 <br />If MANAGER Ak— 011HERAUAtOR®AGENT O <br />9APFLrvristatdwftue;,pva ufwantradw baipb rfgL w Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L dw o varoroperatorof Ow property brawdat the above ante address. tweby audwrine Ga neem of <br />any and all results, geo"niml data an:Vor 0nvi[WnCtbdlhite a55033rWlt htntutlan to In SAN JGWJH COUNTY Palk HExn+SERWCES Ewatm ENYAL HEALTH DMSCN a3 sem <br />as d Is available and at Via same dme it is provided b me or my raprmclGRre. <br />TYPE OF SERVICE REQUESTED: <br />(/� / r G <br />J <br />; <br />�Di1La. (/f'�.L�SA� <br />COMMENTS: <br />PAY M E W, <br />FiECEIVFC- <br />4-5 ej <br />(SOU2 6 <br />SAN JOAOuIPI COUNT <br />�>4.5 <br />PUBLIC HEALTH SERVICES <br />cNVIRONMENTAL HEALTH DIVI€I if <br />INSPECTOR'S SIGNATURE: <br />COMMACTOies SIGRATURE. <br />APPROYEDBY: //./// <br />- <br />Exnzyr.R: qlS 7 <br />DATE: <br />14 <br />ASSKiNID TO: <br />a et <br />EMPLOYEE Q�r>a <br />DATE: <br />. Date Service Completed (if already completed): <br />SERWCECum: p <br />.P f -E y <br />2 3,0 <br />Fee AmountD <br />c�Q <br />J <br />Amount Paid <br />t'aymentDate L� <br />GI <br />Payment Type <br />Check t! <br />Received By: <br />