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SERVICE REQUEST <br /> Type of Suainees or Property FACILITY ID# SERVICE REQUEST# <br /> i4.t=C-WNY UI-I6� �I ( C) .;k <br /> s <br /> OWNER I OPERATOR Bu LUNG PARTY❑ <br /> FAcrt rrr NA►lE WAY �-rIA•sU"(\r L_ <br /> SrTEADDRESs 1'/)07 <br /> -Et:; i '.I l 1 t 1a-M�� �J '�Y <br /> sa..c N,.nn.r wrWlon Sn.i K,m. i AY4 <br /> Malling Address (if DlNerent from Site Address) <br /> Cm' STATE ZIP <br /> PHONE 01 T• APN# LAND USEAPPtJwuN# <br /> ( ) <br /> PNONE}f2 �• BOS DISTRICT " <br /> TLO"Trhco <br /> DE <br /> CONTRACTOR ISER=F REQUESTOR <br /> REQUESTOR BnLen PAM 0'. <br /> Bu&NE"?"E PHONE# _ oc <br /> 76r I I � <br /> MAtEtNCTAonR:=ss1('37 N�'k--1 t /\/� l�VVEL.L p ��iZf ?l� 765 - �'�lC;�', <br /> CttY ��C jf"� STATE / LP Gil C f'L6 <br /> I <br /> BILLING MOWLEDGEMENT: I,the undersigned property or business owner,operator or autho agent of home,adchowiedge tat ad Iia andlor pmol Spec* <br /> ! PUBLIC HEALTH SiRv M ENmONw&aAL HEALTH OmscN hourty ctharyes assodatbd with Cris pro)ed or aahity wo be Mad to me or my business as fdenL%d cn Ihis Ibtm. <br /> Z.t I Aho csrtlfy that I have pmpared this appbcation and that the work to be performed vd be Cale In acmrd�with al SAN JaAam CaurrY Ordinance Codes,Sbndsrrla.STATE,tend <br /> FtU m.Wra. _ <br /> yArPucANT649ATURE C�! � �= '� � — ; DATE <br /> NwmrY!BusmmOwN°R ❑ OPERATORIhwucER ❑ OTHtRAunMr�-DAGENT <br /> <: IAaararrrIsnot mRxiicpoda.waormaw+to&+risMqurw rill. <br /> 6M4RIZATION TO RELEASE INFORMATION:When app8ca*L the owner oroperator of Ca prop"bated at the above ahs address,hwoby aut wilt M M%Mp of <br /> any and aA msulis,geotechnical data amilor envkorunent&V3#A assessment Inbanadon to the Sus JOAoue<CO�M Pueuc HEALTH SPltvtcEs F1N=wAeaAL HEALTH ONM ONAaa 11M <br /> as ft h avattable and at the same time it Is provided Io me or ry ropresentatlm <br /> TYPE OF SERVICE REQUESTED: <br /> i. Tl�NI;: (N�T�C1�TiC-�f.� 2�;'u �-a► <br /> C04YEM: <br /> f. PAYIVIE <br /> RECFIVE <br /> 1 2001 <br /> 'i IWECTOfes SIGNATURE , CONTRA=FeI SpNA RE: <br /> APPROVEDtiY: EIrPtomt / i DArE: <br /> ASS;GMM To: L� , Ewtcrak -Z • D DATE <br /> Data Setvlca Completed-(ft already completed): CODE: -P f E:. <br /> Fels Amount: ' + Amount Paid 7 Payment Date <br /> Ptyment Type Invoices# Check# .a _ �� d 7 Received 8y <br />