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SERVICE REQUEST <br /> SERVICE REQUEST# <br /> FACILITY ID# <br /> / BILLNG PARTY L <br /> Type of Business or Property (? / / <br /> OWNER I OPERATOR Z— Z, -- <br /> � iOe5 COa.5 V q <br /> FACILITY NAME L D ,J, , . 1 �✓ ( Ty" Su l <br /> -5 Strwli� <br /> SITE ADDRESS, /�l} �µN�r oinccen <br /> c_ Site Address) ZIP 9 52 <br /> Mailing Addreossss (lf Differen)t from STATE <br /> CITY 5`(�c, TCs'� LAND USE APPLICATION# <br /> J APN# <br /> PHONE#T 2_q _ LOUTWN CODE <br /> —( 80S DISTRtcT <br /> Fn- <br /> PHONE#2 <br /> CONTRACTORISERNCE REQUESTOR BILLING P <br /> ,(�,��I �� Ett. <br /> REQUESTOR G PHONE# SCI 2- 7- <br /> BUSINESS FAx# ,DCI <br /> T 1 .71Zip <br /> MAILING ADDRESS ( �L STATE /�— <br /> I nn for or audtor¢ed agent of same,adcn.xedge drat all site andlor 911 <br /> CRY /1,J 6(..� business as Identified on tits form <br /> e or business�o r �° or 9ct ltY sdV be bided to me or my <br /> 1,the undersigned Property <br /> assn® CCUNiT Ordinance Codes.Standards.STATE and <br /> BILLING ACKNQWLS D�M�Nru HPxTr+DIVISION hourly with ao SAN JOAQud1 <br /> pUBUC HEALTH SERVICE (tgiun and that the won,to be TlerfomLed`"na be done in accordanceD <br /> I also cerdfy That I have prepared'his aPP <br /> DaTE: nA� <br /> FEDERAL IaYlS. <br /> Q ❑ OTHfRA HOpr�p AGENT e <br /> APPLICANT SIGNATURE: RAUTH REZED roayA6 ub d <br /> QPFRATOR� � ,,,"a M-PNr�'.Pr°d EuthofRe the release Of <br /> PROPERTY I BUSINESS OWNER r of Ne ProPaM hwted atthe above site add RGNa�11Tu HEJ�LTH OrvLR as soon <br /> oWrlP.r or o9ento CGUNTY PuaOC HEALTH SF.WCEs ENA <br /> SEI no,'m TI'er When appl'ta i,,t information to the SAN JOnouW <br /> AUTHOR TION TO RE LEA �7 q / <br /> I"s 9mvded N me or MY rePresemadve. e! 9 <br /> any and a0 msuds.9eotechniral data ardlor emironmentaVsile ass <br /> as it is available and at Me same time Ann <br /> TYPE OF SERVICE REQUESTED• <br /> COMMENTS: <br /> CONTRACTOR`S SIGNATURE: <br /> DATE- <br /> INSPECTOR'S <br /> ATEINSPECTORS SIGNATURE: EYPL�°# <br /> DATE: <br /> APPROVED BY: EmPLOYEEt. <br /> SEFlVICECODE'ASSIGNED 10: - ,U <br /> leted): <br /> Date Service Completed (if already com P <br /> Amount Paid payment Date L)Received By' <br /> Free Amount Check# 0 14.LU03 <br /> Invoice# <br /> Payment Type <br /> ENVIRONMENT NEALT <br /> PERMIT/(""-P" TIFFS <br />