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t <br /> SERVICE REQUEST <br /> Type or Business or Property FAClLf7Y ID 44 SERVICE REQUEST n <br /> +bq-g- 33.5 34 <br /> OWNER OPERATOR BILLING PARTY C <br /> L <br /> FAclury NAME <br /> SITE ADDRESS <br /> SKNum6r Ofrntian 5trr+r Msme Trp. Suiui <br /> Mailing Address (If Different from Site Address) <br /> G,3f1v,-1v til v°y <br /> CITY STATE ZIP <br /> v rte\ .ti G a C4' 6 <br /> PHONE#1 APN# __[LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REoUESTOR / BI6LIHG PARTY❑ <br /> �GC7T i kW J'}f <br /> BUSINESS NAME PHONE# FST. <br /> NLULWG ADDRESSI FA%# <br /> f CRY STATE ZIP 4 � <br /> BILLING ACKNOWLEDGEMENT: I. the undersrgned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project speuhc <br /> Pusuc HEALTH SEF3VICEs ENVIA"WTW.HEALTH OMSION howly charges assasated with this project or acMy will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and thai the work to be performed anal be done in a=rdanee with a!<SAN.IOAOl11N COUNTY Ordinance Codes,Standards,SPATE and <br /> FEDERAL laws. !a tr <br /> APPUC,w1'SIGNaruRE:_ _ — -- _ _. � I}ATE; C514 <br /> r <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR]MANAGER ❑ OTHER AUTHOR=AG24T <br /> 9AFPLc risncte:E+NPzvzprov(ofauthorindontosi rIsrsqu' r;r1e <br /> AUTHC R2ATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property Located at the above site address,hereby authorize the release of <br /> any and all rrsutts,geatechnicz)data and/or a TMrimenolrsite assessment infomladon to The SAN.$ Ouw COUNTY Pv&c HEALTH SERviCES EwncNmENTAL HEALTH OmsioN as soon <br /> fas it is available and at the same time its provided to me or my represengtnre. <br /> 1 TYPE OF SERVICE REQUESTED: f-'P"te V, <br /> COMMEHTS: Ch J <br /> ° PSC ti��p <br /> 'R <br /> gAN JOAQUtN GOUt�TY <br /> I pUSLIG 4i�AL�H S�RVIG�.S <br /> I iNVIFiO�A�EN�AL HEA1-���IVIS4Csfy <br /> INSPECTORS SIGNATURE: CcNTRACTOR s SIGNATURE: <br /> APPROVED BY: -,7 ,K 2— DATEV -o3 <br /> ASSIGNED To: PL �#y <br /> _,C—kZ) RATE: O — Z — v 3 <br /> Date Service Completed (if already completed): SOVAM CODE: °0,3 -P I E- <br /> i <br /> i Fee Amount7 CSO Amount Paid v Payment Date Q _ <br /> Payment Type Invoice# Check# � Received By: <br /> i <br />