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r (SERvium Revleed 8/23/73 <br /> SERVICE REQUEST <br /> tAchfly lO a WOO Ib N —_ <br /> TAr.11lir NAwe <br /> SItE AbOAM <br /> CITY CA 21P [ANV # <br /> I' <br /> RILLINr. PARTY r / N <br /> rAnlr p/OPEaA toa <br /> PNONE M1 t <br /> ORA <br /> PHONE 112 ( t - <br /> t:. A unM <br /> �• - SIAIE LIP <br /> CITY <br /> APO N �Lpixl 06t- ApplleeFlan A <br /> RtlS hist Locatlon Code <br /> ruN,pACtop aal/or /- .� Is WHO PARTY Y / N <br /> SFIIVICE 11EIA1E"04 S1L�J� <br /> PNWE Of () 733 - <br /> NA ILINO An11gE 55 <br /> 3� V� ��+ v � _ FAX M (-)7,33 <br /> ._ � 6;%5,6tlii SIAi ztp <br /> hI1lIN0 ACkNWIEbGENENiI Ir (he trxlerilgned owner, bperstor or agent el Bane, Ncknowtedge that el l,el ke nt.1/or 3qLtLINdOject ARTY m e <br /> h115/EIPo ha!rly cherblA anaoclated with this facility or activity NI11 be billed to the party IdentilTe`tlaJ tthA�tltINO PARTY an <br /> Pawl I of lhla lotm. RECEIVED <br /> U E C 2 3 1388 <br /> ti•. I nlan terilty that 1 have prepared this Appllentlon Atxl that the writ to be performed Will bs S"AA��IINtVUN1 Yh sit CAW <br /> JtlaaU1N tWoll 0rdlnimae CocW and S(Atxlards, StM6 And federal to PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> '`i ''.�` APPUCANir§ SI0NA11RIE ! Vim` �� <br /> 11I11!! bAtl. / 3 9 <br /> Auliml2AtION to RELEASE INNOWttlolle Ili Addition to th! sbovA, Nheh epplleabll, I, the bwner, operator or silent of Aare, of <br /> Nr! brMxrty (ochtbd at lh! Ahova 4116 kldtenA herel»• huthbl•116 the tel"44 o1 Any And A11 tenultb, Deokeehnitel data etxlaw <br /> sF h;vlrormentAl/Alta aAAAANnlht Ihlbttohtlat to SAN JTTAOUIN tO11NtY WWI! 0ALIN SERVICES ENVIRONMENTAL NEALtO DIVISION an soar $10 <br /> AvellAble AM At FhN'eome tlmA It IA ptovlded to hA or W teprlsehtAtive. <br /> -- <br /> NAtUra of Service k!t}Jletl strvlca t«IA <br /> Aselbtmd to Enployee 0 bete / / <br /> Os(e ServleA tormleled _i—l— iurthet Actlon kequlred! y / N phocRAN ELEMENt UM <br /> i <br /> res Amami Amami psld bet! of Psyment payment type check N Reevd Ry <br /> 329g <br /> gTNS /_/ SUPV �/ /_ Acctl _1_ UNIT CLk <br /> r , <br />