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Ll 2L f1JJJ1 dL:al Fll-IH FLLIK NG;r j'J <br />S-F,,j :F wrni x-zT <br />Type of 6ibuitns or Property <br />FACILITY 101 Sr-WCE rREQLIESr <br />MARINA <br />N-483 <br />UNNERI OPERA70R <br />EILLING FAF Y <br />THE PEGASUS GROUP / VILLAGE WEST MARINA <br />FACMn NNIS <br />VILLAGE WEST MARINA <br />sr. �DFtEss <br />EiFLOY>;#; <br />CLAM <br />6649 sa,.rNu.ew <br />ate, <br />EMBARCADERO DRcb,.m , <br />Typo I � <br />MaH;ng Address at Different from Site Addressl <br />Cly STAB L7 <br />P+40?og 91 <br />APN $ <br />LAtro USEAPPU AIMI k <br />Prlor fi t a'• SOS 7lsrarr LccAncwCoca. <br />CONTRACTOR/ SERVICE REOUESTOR <br />REauwcR C3.LtHC PARTY ❑ <br />Buss Narle <br />PNtun <br />MALmG ArorEss <br />FAzI <br />�r i r SIAM Z:P <br />BILLING ACMOWLEDGEMENT: L the ueder;Aed property ar busfnesz owner, operator of authorized agent of same, acszwiecp = of slth arwQCr prge—, spe&( <br />PLUX HEALTH 6EFmcu Cwrrmcw&wAL'IJEALTH Dwirrr .io+ (''Jfge5 a=mbc d Kith Ihli pmt cr acNty will be baled to me cr my buzz ass �3 Vlendled on trig arra <br />I also Qv. Jff drat I `rays prepared this applmton and To to wertr in ha perterned mA be dtne m aemmarhm Hifi of Sa JdA=N CUtWrY Crmrraaca Codas, Stardlrc' , S7AT- anc <br />F � FTs. <br />A*=T S Ate= DIITE 03-07-01 <br />PRCPEATYIBLSUEWCNNER ❑ OP-wm OTHER AUTMCFIM)Amlfr Q HARBORMASTER <br />dAPPJi'.Wr si rzt file B4rA4' PMi ry pr9o/ 0(ir71}70'C'if%n tD si�7 t+ fagvlvd rf f e <br />AUTifORiZATION TO RELEASE INFOR,YAT10A-man act3bfe, L the owner or operator of the X.?pefty kxated at die above sae address, hereby audjcff d J)e micas& of <br />any and al result, goot dmeow date arKwor envknmeomY_ite assessme-a bnfCx00Cr, tote SAH JoAarN COUNTY PL'L1c H&CH &5CYtGS F—ViF r+.a:lrrAL NExTH CNLS;rA as soon <br />7a its available and A the sante Time U3 provided b roe a r4y reprrsersti m <br />TYPE of SERVICE Rr-mEsm: <br />CaruiFxT� <br />INSPSCTtlR'S SlGNAn1RE`. <br />COtITRAGTDR'S SlaruruR - <br />APPttDvmaY: <br />EseFM^Y j: <br />DATe: <br />AsmGNED TM <br />EiFLOY>;#; <br />CLAM <br />Date Service C=Plened (if already compieted): <br />S vt~Coar• <br />P IEE <br />Fop Amount <br />Amount Paid Payment Date <br />Payment Type <br />Invoice # <br />Check 9 Received 3y- <br />14 <br />